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State Funded Initial Eligibility Form
In order to start the registration process for the 2023-2024 school year, please complete this form. Be sure to include your school preference by priority.
* Indicates required question
All fields marked with * are required and must be filled.
Your answer
Child's name (First and last name):
*
Your answer
Child's Primary Language
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
Home Telephone:
*
Your answer
Email address:
*
Your answer
Does your child receive services (speech, OT) from the school district through and Individualized Education Plan (IEP)?
*
Yes
No
Do you have a social worker assigned?
*
Yes
No
Is a family member receiving benefits from the following programs: Cal-Fresh, CalWorks, WIC, Head Start, Section 8 (housing assistance), or Medical.
*
Yes
No
If you answered yes to the question above, please choose the type of program from the list.
Cal Fresh
CalWorks
WIC
Head Start
Section 8 (housing)
Medical
Clear selection
Who is the member of the family participating in the program?
Your answer
Address:
*
Your answer
City:
*
Your answer
Zip code:
*
Your answer
Parent #1/Guardian Name:
*
Your answer
Address include city and zip code or check below if same:
Your answer
Check if same or check if not at home:
*
Check here if same
Not at home
Required
Cell phone:
Your answer
Parent #2/Guardian Name:
Your answer
Address, include city and zip code check below if same:
Your answer
Check if same of check if not at home
Check here if same
Not at home
Cell phone:
Your answer
Next
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