Pre-Application

Names

Child Name(Required)

First Middle Last

Child DOB(Required)

Parent/Guardian(Required)

First Middle Last

Phone/Email

Phone One(Required)

Phone Two

Cell Phone

Contact Time

Address Information

Living Address(Required)

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Alternate Contact

Alternate Contact Name

First Last

Alternate Contact Phone

Family Information

Number of people in family

Last year's household income

Who does the child live with

Other Living Arrangement(Required)

Additional Information

Additional Questions

Check all that apply

My family receives cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program.

My family receives Supplemental Security Income.

My family is experiencing Homelessness.

My family receives services from WIC.

My family receives services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps.

At least one parent/guardian is an active duty member of the United States military.

At least one parent/guardian is a veteran of the United States military.

You must click 'Submit' below to send this pre-application. After submitting, a CAPCC Early Childhood employee will contact you to finish the application process.

Name

This field is for validation purposes and should be left unchanged.

Names

Phone/Email

Address Information

Alternate Contact

Family Information

Additional Information

Contact

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