Santa Rosa Junior College Child Development Department

Children's Center Eligibility List Application Form

Date Requested:

This is a (select one):

New Application
Revised Application

I'm interested in (select one):

Subsidized child care
Non-Subsidized child care

Parent's Information

Parent 1 First Name:

Home Phone Number:

Parent 1 Last Name:

Parent 1 Work Number:

Parent 2 First Name:

Parent 2 Work Number:

Parent 2Last Name:

Home Address:

Parent 1's Occupation:

City or Town:

Parent 2's Occupation:

Zip Code:

Parent's
Email:

Children's Information

Child's Name: Last	First	Date of Birth
Child's Name: Last	First	Date of Birth
Child's Name: Last	First	Date of Birth

To Be Completed by Those Requesting Subsidized Slots

Parent 1's Social Security Number:

Family Size:

Parent 1 Employer:

Number of Children:

Parent 1 School:

Number of Adults

Parent 2's Social Security Number:

TANF

Parent 2 Employer:

Non-TANF

Parent 2 School:

Applicant: In order for us to rank your priority per California Dept. of Education guidelines it is necessary that we know your accurate gross monthly income. This information will be kept confidential. In stating your gross monthly income please use the following formulas:
1. Please include all sources of income such as child support, unemployment, earnings from work, etc. For subsidized slots, we need gross not net, monthly income.
A. If your income is received weekly: use your gross X 4.33 = monthly gross
B. If your income is received every two weeks: use your gross X 2.17 = monthly gross
C. If your income is received twice each month: use your gross X 2 = monthly gross
If your income is variable, add up your gross income for the past 12 months.
If you are self-employed, we use your net monthly business income. (Gross business earnings - business expenses = net business income).

Gross Monthly Income

Note: All applicants are urged to contact Sonoma County's Community Child Care Council at 707.544.3077 for other child care options.

SRJC Child Development Department
1501 Mendocino Ave. Santa Rosa, CA 95401
Director 707-527-4315 Fax 707-522-2625
Email us at:lkelly@santarosa.edu
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