Waiting-List-App-English by changcheng2

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									                                                 School Readiness Programs
                                                 WAITING LIST APPLICATION
                                 ALL APPLICABLE INFORMATION MUST BE COMPLETED
             *SSN is not required for eligibility and services will not be denied due to failure to provide a SSN
                                   *Family Information if living in the household- Must be Completed*
                                                                                              Ethnicity/Race
                                                                               Gender         Circle all that
                                                                                                                          Place of Employment/School
                  Name/Social Security #                     Date of birth
                                                                                 M/F         apply (see box
                                                                             (circle one)        below)

                                                                                                                Employer/School:___________________________________
Parent/Guardian
                                                                              M or F                            Address:__________________________________________
Name_________________________________________________                                         H / NonH_
                                                                                              W B A H AI        Work Phone : (________)____________________________

*SS#_________________________________________________                                                           Hourly Wage ___________ # hours worked per week _______




                                                                                                                Employer/School:___________________________________
Parent/Guardian
                                                                              M or F                            Address:__________________________________________
Name_________________________________________________                                         H / NonH_
                                                                                              W B A H AI
                                                                                                                Work Phone : (________)____________________________
*SS#
                                                                                                                Hourly Wage ___________ # hours worked per week _______
_____________________________________________________
                  Ethnicity – Hispanic or Non-Hispanic             Race – White / Black / Asian / Hawaiian / American Indian

Home Address: _______________________________________________________________________ Apt / Lot # _____________
City:____________________________________________ State:_____________________________ Zip Code:________________
Mailing Address(If Different from Home Address):__________________________________ City/State/Zip Code: _______________________
Home Telephone #: ________________________ Cell telephone #:_________________                                   Are you receiving SSI? Yes No
Email: _______________________________________________ Language spoken at home: _________________________
Parent/Guardian Marital Status (please check one)         Married            Single        Separated           Divorced         Widowed
How many people live in your household: # of adults _______ #of children _______
Define relationship of all adults living in household (boyfriend, child over 18, mother-in-law, etc.)______________________________________

              List All Children to be Placed on the Waiting List – ALL INFORMATION MUST BE COMPLETED
                                                                       Relationship         Ethnicity/Race
      Child’s Legal Name              Date of       Gender
                                                                          to child           circle all that
                                                                                                                       Social                 Child’s Current Grade Level
      (first and last name)            Birth         M/F                                                              Security #                     (if applicable)
                                                                    (see codes below*)           apply

                                                                                             H / NonH_
                                                                                             W B A H AI

                                                                                             H / NonH_
                                                                                             W B A H AI

                                                                                             H / NonH_
                                                                                            W B A H AI

                                                                                             H / NonH_
                                                                                             W B A H AI

                   *Codes:    C = Natural/Adopted Child       G = Grandchild             N = Niece/Nephew         F = Foster          O = Other

COMPLETE AND MAIL THIS FORM TO:                           EARLYCHILDHOOD/SCHOOL READINESS PROGRAMS
                                                          5701 E. HILLSBOROUGH AVENUE, SUITE 2301
                                                          TAMPA, FLORIDA 33610
                                                          ATTENTION: SR Waiting List Department
Applications may be faxed to 813-744-6753 or emailed to earlychild@sdhc.k12.fl.us. You will receive information to update your
application every six months. You are required to contact SR to update information as changes occur. We cannot estimate the time you
will be on the waiting list. When funds are available, based on coalition priorities and the date children are placed on the waiting list you
will receive an invitation by US Mail to come into the office to determine if you are eligible.
If you have any questions regarding the waitlist process, please contact SR Waiting List Staff at 813.744.8941 ext. 532.

Families may contact Child Care Resource and Referral at www.elchc.org/ccrr_web_intake.html/ to request a listing of
providers that may offer scholarships, negotiated rates, or a sliding fee scale rate.
                                                                                                                                               Waiting List Application 10/3/13

								
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