Application for Enrollment

* Your Full Name: (person submitting)

* California State Employee: Yes No
Note: State employment is verified before enrollment

* Relationship to Child:

* Your Email Address:

Alternate Email Address:

* Physical Address:

* City:

* State/Province: /

* Country:

* Zip:

* Your Phone Number: ( ) - (home number)

* Your Cell Number: ( ) - (or alternate number)

* Child's First Name:

* Child's Last Name:

* Desired Enroll Date: Note: This application is viable for one year and must be renewed annually to maintain consideration

* Number of Siblings:

Additional Information

Please supply information about second parent/ guardian (if applicable)

Full Name:

Email Address:

Phone Number: ( ) - (home number)

Cell Number: ( ) - (or alternate number)

California State Employee: Yes No
Note: State employment is verified before enrollment

Relationship to Child:

How did you hear about us?

Source:

Details: