Pregnant Mother Information – ApplicantFull Legal Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Due Date(Required) MM slash DD slash YYYY Upload Pregnancy VerificationMax. file size: 100 MB. Race(Required) Asian American Indian/Alaskan Native Black/African American Multiracial/Biracial White Hawaiian / Other Pacific Islander Hispanic/Latino(Required) Yes No Primary Language(Required) English Spanish Other Secondary Language English Spanish Other Street Address(Required)Apt. #CityState– Select State –AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip CodeMailing Address (if different) Address Po Box City State Zip Code Home TelephoneCell PhoneEmail Address Currently enrolled in school/training?(Required) Yes No School NameHighest Level of Education(Required) Less than High School High School Diploma GED Some College AA/AS BA/BS MA/MS Are you currently working?(Required) Yes No Working Status Part-time Full-time Unemployed Disabled Self Employed/Independent Contractor Source(s) of income(Required) Wages TANF CalWORKS SSI Disability Unemployment Child Support Alimony/Spousal Support Check all that applyUpload Income Verification Drop files here or Select files Max. file size: 100 MB. Prenatal Health InformationDo you need assistance in obtaining health insurance? Yes No Health Insurance Provider Medi-Cal Private Insurance Indian Health Benefits No insurance Date of last prenatal exam MM slash DD slash YYYY Upload Most Recent Prenatal Exam Drop files here or Select files Max. file size: 100 MB. Date of last dental exam MM slash DD slash YYYY Dentist NameUpload Most Recent Dental Exam Drop files here or Select files Max. file size: 100 MB. Is your pregnancy considered high risk? Yes No If yes, please explainParent/Guardian B InformationLiving in the home(Required) Yes No Full Name: First Middle Last Date of Birth MM slash DD slash YYYY Gender Male Female Marital Status Married Single Race Asian American Indian/Alaskan Native Black/African American Multiracial/Biracial White Hawaiian / Other Pacific Islander Hispanic/Latino: Yes No Parent Primary Language English Spanish Other Parent Secondary Language English Spanish Other Home TelephoneCell PhoneEmail Address Currently enrolled in school/training? Yes No School NameHighest Level of Education Less than High School High School Diploma GED Some College AA/AS BA/BS MA/MS Are you currently working? Yes No Working Time Part-time Full-time Unemployed Disabled Self Employed/Independent Contractor Source(s) of income Wages TANF CalWORKS SSI Disability Unemployment Child Support Alimony/Spousal Support Check all that applyUpload Income Verification Drop files here or Select files Max. file size: 100 MB. Family InformationFamily Status Two Parent Family Single Parent Family Single Parent Family with Partner Foster Family Guardianship Number of adults in the familyNumber of Children in the familyList full names and birthdates of all children in the familyFull NameDate of BirthGender Add RemoveUpload Birth Certificates Drop files here or Select files Max. file size: 100 MB. Family CircumstancesHas your family experienced any of the following in the past 12 months? Parent/Guardian in Drug/Alcohol Treatment Parent/Guardian is Disabled Open CPS Case Domestic Violence Parent/Guardian is Incarcerated Parent/Guardian Active Duty US Military Parent/Guardian Veteran US Military Agency Referral No Transportation Restraining Order Child Abuse or Neglect Healthy Babies Other If otherIf Agency ReferralDoes your family receive WIC?(Required) Yes No Does your family receive CalFresh?(Required) Yes No Please add any other concerns you have for your pregnancy and/or your familyWhich language does your family prefer for spoken? English Spanish Other Which language does your family prefer for Written? English Spanish Other Are you or an immediate family member currently an employee of KidZCommunity? Yes No If yes, relationship to you? Self Parent Spouse Child Sibling Other Residence InformationDoes your family Live in permanent housing Live in a car, park, or other public place Lack regular nighttime housing Live in a hotel/motel Live in a shelter Temporarily share a home with other people/Actively seeking alternate housing Upload Residency Verification Drop files here or Select files Max. file size: 100 MB. Recruitment TrackingHow did you hear about our program? Event Someone came to my door Banner/Yard Sign KidZCommunity Staff Community Agency Flyer/Postcard/Bookmark Past/Present Parent School District Website Other Please describe how you heard about our programIf OtherI certify the information I have provided is accurate to the best of my knowledge. I understand I must provide all required documentation in order for my application to be processed. I understand that completion of this application does not guarantee enrollment.Parent/Guardian SignatureDate Signed MM slash DD slash YYYY CAPTCHA