Early Childhood Division Registration

Registration

D.O.B. / /

Gender:

Male Female

Parents' Marital Status:

Married Separated Divorced

Father's Information

Mother's Information

Does child get services?

Yes No

Does your child have allergies?

Yes No

Does your child have any medical conditions or health concerns?

Yes No

Emergency Contacts

Billing

A $250 non-refundable deposit is required to reserve a spot for your child

Exp.

You work 10+ hours per week
You are in an educational or vocational training program
You have been looking for work
You live in temporary housing (priority access)
You are attending services for domestic violence
You are receiving treatment for substance abuse

Family Size	Monthly Income Eligibility	Annual Income Eligibility
2	$6,156	$73,869.56
3	$7,604	$91,250.63
4	$9,053	$108,631.70
5	$10,501	$126,012.77
6	$11,949	$143,393.84
7	$12,221	$146,652.80
8	$12,493	$149,911.75
9	$12,764	$153,170.70
10	$13,036	$156,429.65
11	$13,307	$159,688.60
12	$13,579	$162,947.55
13	$13,851	$166,206.50
14	$14,122	$169,465.45
15	$14,394	$172,724.40
16	$14,665	$175,983.35
17	$14,937	$179,242.31
18	$15,208	$182,501.26

Persons in Family/Household	Poverty Guideline
2	$20,440
3	$25,820
4	$31,200
5	$36,580
6	$41,960
7	$47,340
8	$52,720

For families/households with more than 8 persons, add $5,380 for each additional person.