Request to begin enrollment process for Options for Learning programs

This form is not an application for services. This is the first step in the enrollment process and preliminary determination of eligibility for services.

Parent/guardian's first name*

Answer Required

Parent/guardian's last name*

Answer Required

Parent/guardian's phone number*

Number Required

Child's full name*

Answer Required

Child's date of birth*

Answer Required

Home street address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip code*

Answer Required

If you are interested in care for additional children, please indicate their age(s) (check all that apply):

Answer Required

0-2

3-5

School-age (grades TK-8)

Type of care needed (check all that apply)*

Answer Required

Part-day preschool

Full-day infant/toddler/preschool

Before-school K-8 (school-age)

After-school K-8 (school-age)

After-school TK

Child care setting desired (check all that apply)*

Answer Required

Center-based

Family child care home

Home-based program

In-home care (family/friend/neighbor)

Out-of-home care (family/friend/neighbor)

City where care is needed*

Answer Required

Need for services (check all that apply)*

Answer Required

Working

Seeking employment

Attending school (vocational or educational program)

Incapacitated

Unemployed

Seeking permanent housing

Welfare-to-work activities (CalWORKs programs)

Is your family currently receiving (or has received in the past two years) cash aid?*

Answer Required

Yes

Is the child at risk or a recipient of Child Protective Services?*

Answer Required

Yes

Is your living situation stable?

Answer Required

Yes

How did you hear about us?*

Community event, advertisement, family/friend, social media, etc.

Answer Required

Thank you for your inquiry. Please allow two business days for a response.

Please fix the highlighted areas below before submitting.

Request to begin enrollment process for Options for Learning programs