Child InformationChild’s Legal Name:(Required) First Middle Last Date of Birth:(Required) MM slash DD slash YYYY Upload Birth CertificateMax. file size: 100 MB. Gender(Required) Male Female Race(Required) Asian American Indian/Alaska Native Hawaiian/Other Pacific Islander Black/African American Multiracial/Biracial White Hispanic/Latino(Required) Yes No Primary Language(Required) English Spanish Other Enter Primary LanguageSecondary Language English Spanish Other Enter Secondary LanguageStreet Address(Required)Apt. #CityState– Select State –CaliforniaZip CodeMailing Address (If different) Address Po Box City State Zip Code Medical InformationHealth Insurance Not Insured Medi-Cal Indian Health Benefits Private Insurance If Private Insurance(Required)Physician NameDate of Last Physical Exam MM slash DD slash YYYY Upload Most Recent Physical ExamMax. file size: 100 MB. Dental InformationDental Insurance Not Insured Medi-Cal Indian Health Benefits Private Insurance If Private Insurance(Required)Dentist NameDate of Last Dental Exam MM slash DD slash YYYY Upload Most Recent Dental ExamMax. file size: 100 MB. Diagnosed Medical Issues(Required)Please indicate any diagnosed medical or biological issues currently affecting your child. Check all that apply No diagnosed medical issues Asthma Diabetes Heart Condition Eczema Visual Impairment Food Allergy Seizure Disorder Traumatic Brain Injury Bee Sting Allergy Hearing Impairment Other Please list all food allergiesPlease list the medical issueDoes your child require daily medication for diagnosed medical issues? Yes No Diagnosed Disabilities(Required) No Diagnosed Disability Autism Emotional/Behavioral Speech Delay Orthopedic Impairment Developmental Delay Other Check all that applyDate of Last IEP/IFSP(Required) MM slash DD slash YYYY Enter the DisabilityPlease upload most recent IEP/IFSPMax. file size: 100 MB. Parent/Guardian A InformationParent A Full Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Relationship to Child(Required)Marital Status(Required) Married Single Gender(Required) Male Female Race(Required) Asian American Indian/Alaska Native Black/African American Multiracial/Biracial White Hawaiian / Other Pacific Islander Hispanic/Latino:(Required) Yes No Pregnant Yes No Due Date MM slash DD slash YYYY Parent Primary Language(Required) English Spanish Other Enter Parent Primary LanguageParent Secondary Language English Spanish Other Enter Parent Secondary LanguageHome 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 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. Parent/Guardian B InformationLiving in the home(Required) Yes No Parent B Full Name: First Middle Last Date of Birth MM slash DD slash YYYY Relationship to ChildMarital Status Married Single Gender Male Female Race Asian American Indian/Alaska Native Black/African American Multiracial / Biracial White Hawaiian / Other Pacific Islander Hispanic/Latino: Yes No Pregnant Yes No Due Date MM slash DD slash YYYY Parent Primary Language English Spanish Other Enter Primary LanguageParent Secondary Language English Spanish Other Enter Secondary LanguageHome 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 Status 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 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 family Full Name First Middle Last Date MM slash DD slash YYYY Select GenderSelect GenderMaleFemaleUpload Birth CertificatesMax. file size: 100 MB. Family CircumstancesIs your family currently experiencing any of the following? Check all that apply. 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 of US Military Agency Referral Restraining Order Child Abuse or Neglect Healthy Babies Other If otherDoes your family receive WIC?(Required) Yes No Does your family receive CalFresh?(Required) Yes No Please add any other concerns you have for your child and/or your familyWhich language does your family prefer for spoken? English Spanish Other Enter the language your family prefers to speakWhich language does your family prefer for written? English Spanish Other Enter the language your family prefers to writeAre 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 Information(Required)Does 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. Does your child need full day childcare? Yes No Does your child need transportation to/from childcare?Transportation is offered in limited areas. Yes No 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 usI 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 SignatureName(Required) First Last Date Signed MM slash DD slash YYYY CAPTCHA