NamesChild Name(Required) First Middle Last Child DOB(Required) MM slash DD slash YYYY Parent/Guardian(Required) First Middle Last Phone/EmailPhone One(Required)Phone TwoCell PhoneEmail Contact Time Address InformationLiving Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Alternate ContactAlternate Contact Name First Last Alternate Contact PhoneFamily InformationNumber of people in familyLast year's household incomeSelect One$0-$10,000$10,001 - $25,000$25,001 - $40,000$40,001 - $55,000$55,001 - $70,000$70,001 - $85,000Over $85,000Who does the child live withSelect OneMotherFatherBoth Mother & FatherGrandparentsOther Explain BelowOther Living Arrangement(Required) Additional InformationAdditional QuestionsCheck 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.CommentsThis field is for validation purposes and should be left unchanged.