ATCAA Early Childhood Services
Head Start/State Preschool
ATCAA General Child Care ATCAA Head Start/State Preschool
935 S. State Highway 49 427 Highway 49 #305
Jackson, CA 95642 Sonora, CA 95370
Re: Parent’s Name: ________________________________________________
Certification: The parent listed above requires childcare services due to the
family being homeless and seeking permanent housing. If the parent has a
written plan for seeking permanent housing please attach a copy.
Name of Agency: __________________________________________________
Agency Phone # ____________________
Signature of representative: ___________________________ Date: __________
I hereby give my consent that an ATCAA Early Childhood Services Representative
may contact the above named agency to gather further information about my
plan in seeking permanent housing.
Signature of parent: ________________________________ Date: __________