Eligibility List Online Application

  
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Primary Parent     Secondary Parent First Name * Last Name * Home Phone * Alternate Phone Date of Birth (mm/dd/yyyy) * Marital Status Please Select Single Married Divorced Separated Gender Please Select Male Female Address 1 * Address 2 City * Please Select Castro Valley Fremont Hayward Newark Oakland San Leandro San Lorenzo Union City State * Zip Code * Please Select 94601 94603 94605 94607 94608 94612 94621 94546 94552 94541 94542 94544 94545 94546 94552 94580 94577 94578 94579 94560 94536 94538 94539 94555 94587 94602 94606 94609 94610 94611 94618 94619 County * Alameda Email * An email address is required to complete this application. We will use this email to communicate with you in the future. Relationship to Child(ren) * Please Select Parent Grandparent Guardian Foster Parent Other Father Mother Preferred Language * Please Select English Spanish Primary Language Please Select Arabic Armenian Assyrian Burmese Cantonese Cebuano (Visayan) Chalden Chamarro (Guamanian) Chaozhao (Chaochow) Croation Dutch English Farsi French German Greek Gujarati Hebrew Hindi Hmong Hungarian Ilocano Indonesian Italian Japanese Khmer (Cambodian) Khmu Korean Kurdish Lahu Lao Mandarin (Puntonghua) Marchallese Mien Mixteco Native American Languages Other Languages of China Other Languages of the Philipines Other non-English Pashto Pilipino (Taglog) Polish Portuguese Punjabi Rumanian Russian Samoan Serbian Serbo-Croation Spanish Taiwanese Thai Toishanese Tongan Turkish Ukrainian Urdu Ethnicity Please Select CAUCASIAN (NON-HISPANIC) AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN HISPANIC OR LATINO NATIVE HAWAIIAN OR PACIFIC ISLANDER UNKNOWN/DECLINE TO STATE Are you currently receiving cash aid or have you received cash aid in the last 24 months? * Yes No Have you received CalWORKs Cash Aid in the last 24 months? * Yes No       Case Number * Reason for Needing Child Care * Actively Seeking Employment Education Or Training Incapacitated Protective Services Seeking Permanent Housing Working Primary Employer Zip Code Primary School Zip Code First Name * Last Name * Home Phone * Alternate Phone Date of Birth (mm/dd/yyyy) * Marital Status Please Select Single Married Divorced Separated Gender Please Select Male Female Ethnicity Please Select CAUCASIAN (NON-HISPANIC) AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN HISPANIC OR LATINO NATIVE HAWAIIAN OR PACIFIC ISLANDER UNKNOWN/DECLINE TO STATE Relationship to Child(ren) * Please Select Parent Grandparent Guardian Foster Parent Other Father Mother Preferred Language * Please Select English Spanish Primary Language Please Select Arabic Armenian Assyrian Burmese Cantonese Cebuano (Visayan) Chalden Chamarro (Guamanian) Chaozhao (Chaochow) Croation Dutch English Farsi French German Greek Gujarati Hebrew Hindi Hmong Hungarian Ilocano Indonesian Italian Japanese Khmer (Cambodian) Khmu Korean Kurdish Lahu Lao Mandarin (Puntonghua) Marchallese Mien Mixteco Native American Languages Other Languages of China Other Languages of the Philipines Other non-English Pashto Pilipino (Taglog) Polish Portuguese Punjabi Rumanian Russian Samoan Serbian Serbo-Croation Spanish Taiwanese Thai Toishanese Tongan Turkish Ukrainian Urdu Email Are you currently receiving cash aid or have you received cash aid in the last 24 months? * Yes No Have you received CalWORKs Cash Aid in the last 24 months? Yes No Reason for Needing Child Care * Actively Seeking Employment Education Or Training Incapacitated Protective Services Seeking Permanent Housing Working Secondary Employer Zip Code Secondary School Zip Code

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