Kids 1st Learning Center

Initial Application

Hi parents, please provide all the information below. Hola padres, por favor complete el formulario.

Email *

Primary Parent First and Last Name/ Nombre del Padre principal *

Home Address/ Direccion: *

Phone Number/ Celular # *

Preferred Language/Idioma preferido: *

English

Spanish/Español

Single Parent? Padre (Madre) Soltero(a)? *

Yes/Si

Total Household Monthly Income (both parents, if applicable)/ Ingreso mensual total del hogar (ambos padres, si corresponde) *

Family size (including children under 18, unless currently attending high school) / Tamaño de la familia (niños menores de 18 años a menos que asistan actualmente a la escuela secundaria) *

Status/ Estatus *

Working/Trabajando

Student/Estudiante

Seeking employment/Buscando empleo

Incapacity/Disability; Incapacidad/Discapacitado

Homeless/Familia sin vivienda

Protective Services/Servicios de proteccion

Age of Child(ren)/ Edad del Nino(s) *

How did you hear about us?/Cómo se entero de nosotros? *

Child(ren) Date of Birth/ Fecha de nacimiento *

Site Preference/ Preferencia de sitio *

Pacoima/San Fernando- ages 18 mos-5 yrs (currently served through Pacoima center)

Downey- (ages 3-5 yrs only)

Bell Gardens- (ages 3-5 yrs only)

Cudahy- (ages 3-5 yrs only)

Baldwin Park- (ages 3-5 yrs only)

Family Home Network- ages 0-5 yrs (available in San Fernando Valley)

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