EARLY CHILDHOOD EDUCATION SANTA ANA UNIFIED SCHOOL DISTRICT Carver 1401 W Santa Ana Blvd Davis 1405 N French St Diamond 1450 S Center St New - Esqueda 2240 S Main St Franklin 210 W Cubbon St Fremont 1930 W 10th St Garfield 850 Brown St Heninger 417 W Walnut St New - Jefferson 1522 W Adams St New - King 1001 Graham Ln Lincoln 425 S Sullivan St Lowell 700 S Flower St Madison 1124 E Hobart St Martin 939 W Wilshire Ave Mitchell 3001 W Harvard St New - Monroe 417 E Central Ave Pio Pico 931 W Highland St Walker 811 E Bishop St Warwick 780 S Lyon St Washington 910 W Anahurst Pl Wilson 1317 N Baker St Preschool Program that offers: Hot Lunch daily Developmentally appropriate academic curriculum (Aligned to District curriculum) Low student to teacher ratio Inclusion opportunities Health and Nutrition Services Referrals to Community Support Services Parent education, training and support Program Requirements: ü Family must provide birth certificates for all your children, proof of address and proof of income. ü Children must be 3 years old by September 1, 2016. ü Children mmust have a current physical, TB Test, dental check-up and immunization record. ü INCOMPLETE PACKETS WILL NOT BE ACCEPTED. ü Children must wear a school uniform ü Parent must participate – stay to read the first 15 minutes, helper in the classroom twice a month, must be immunized against influenza, pertussis and measles. Also, must have a current TB Test and current ID. ü Family must maintain excellent attendance and be on time everyday. ü PLEASE ATTACH MOST RECENT PAYSTUB TO THIS FORM For more information please contact ECE office at: (714) 431-7580 (Available Monday-Friday from 7:30am-4:00pm) Please complete and return the attached preliminary application at: 1629 S. Center St., Santa Ana, CA 92704
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EARLY CHILDHOOD EDUCATION...Early Childhood Education 2016-2017 Eligibility Questionnaire Note: This is a preliminary application. It does not guarantee your child’s placement in
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SANTA ANA UNIFIED SCHOOL DISTRICT Early Childhood Education
2016-2017 Eligibility Questionnaire
Note: This is a preliminary application. It does not guarantee your child’s placement in the program.
Children must be 3 years old by Sept. 1st of the school year they start. *Parents may drop off preliminary application at 1629 S. Center St., Santa Ana, CA 92704
FAMILY INFORMATION
Child’s Name: Date of Birth: □ Male □ Female
Father’s Name: Mother’s Name:
Telephone #1: Telephone #2: Telephone #3:
Address: Zip Code: Email: Family Status: □ Single Parent □ Two Parent Family Does your child have an IEP? □ Yes □ No
Please check the school of your choice: □Carver □Davis □Diamond □Esqueda □Franklin □Fremont □Garfield □Heninger □Jefferson □King □Lowell □Lincoln □Madison □Martin □Mitchell □Monroe □Pio Pico □Walker □Warwick □Washington □Wilson
OTHER CHILDREN LIVING IN YOUR HOME AND UNDER YOUR CARE Last Name First Name Date of Birth School Attending
INCOME: PROOF OF INCOME MUST BE SUBMITTED DURING THE APPLICATION PROCESS Father’s Gross Income
Company Name Receives Payment: Gross amount paid per period Cash or Check
Please check all that you receive: □ Unemployment/Disability $____________ □ Child Support $____________
□ TANF/CalWORKs/Cash Aide $___________ □ Spousal Support $____________
□ Other ________________ □ Food Stamps $____________
Parent/Guardian Signature: Date: With my signature, I certify that the above information is true and correct.
For Agency use only. Do not write below this line
Family Size: Monthly Gross Income Rank: Lives in SA? Waitlist ID# 1: Waitlist ID# 2:
DISTRICTO ESCOLAR UNIFICADO DE SANTA ANA Programa de Educación Temprana Infantil
2016-2017 Cuestionario de Elegibilidad
Nota: Esta es una aplicación preliminar. No garantiza que su hijo/a tenga un lugar asegurado en el programa.
Los niños deben tener 3 años de edad para el día 1 de septiembre del año escolar en el que inician. Los padres pueden llevar la solicitud preliminar al 1629 S. Center St., Santa Ana, CA 92704.
INFORMACION DE LA FAMILIA
Nombre del Niño/a: Fecha de Nacimiento: Sexo: □ M □ F
Nombre del Padre: Nombre de la Madre:
Telefono #1: Telefono #2: Telefono #3:
Direccion: Codigo Postal: Correo
Electronico: Estado Civil: □ Padre/Madre Soltero □ Familia en Pareja Tiene el niño/a un IEP? □ Si □ No
Por favor marque la escuela de su elección: □Carver □Davis □Diamond □Esqueda □Franklin □Fremont □Garfield □Heninger □Jefferson □King □Lowell □Lincoln □Madison □Martin □Mitchell □Monroe □Pio Pico □Walker □Warwick □Washington □Wilson
OTROS HIJOS QUE VIVEN EN LA MISMA CASA Y QUE ESTEN BAJO SU CUIDADO Apellido Nombre Fecha de Nacimiento Escuela
INGRESOS: SE DEBE PRESENTAR PRUEBA DE INGRESOS DURANTE EL PROCESO DE APLICACIÓN Ingresos Brutos del Padre
Nombre de la Compania Recibe Pago: Ingresos bruto por periodo Efectivo/Cheque
□Semana – □2 Semanas – □2 veces al Mes – □Mes
□Semana – □2 Semanas – □2 veces al Mes – □Mes
Ingresos Brutos de la Madre
Nombre de la Compania Recibe Pago: Ingresos bruto por periodo Efectivo/Cheque □Semana – □2 Semanas –
□2 veces al Mes – □Mes
Por favor, marque todas las que recibe: □ Desempleo/Discapacidad $____________ □ Manutención de los hijos $____________
□ TANF/CalWORKs/Ayuda Monetaria ______ □ Manutencion de esposo/a $____________
□ Otro ________________ Estampillas de Comida $____________
Firma del Padre/Tutor: Fecha: Con mi firma certifico que la información anterior es verdadera y correcta.
For Agency use only. Do not write below this line Family Size: Monthly Gross Income Rank: Lives in SA? Waitlist ID# 1: Waitlist ID# 2: