Butte College Child Development Center

Enrollment Application

Parent Information

*Parent 1#

Name______

*Mailing Address______

StreetCityStateZip Code

Phone______*Cell Phone______

*Email______*Butte College ID #______

Parent 2#

Name______

Mailing Address______

StreetCityStateZip Code

Phone______Cell Phone______

Email______Butte College ID #______

Child(ren) Information

*Childs Name______*Birthday ______F or M

Childs Name______Birthday ______F or M

Childcare NeedsPlease Check All That Apply

Full DayA.M. Half Day P.M. Half Day

(7:30am – 5:00pm) (7:30am – 12:00pm) (12:30pm – 5:00pm)

Mon. ______Mon.Mon. ______

Tues.Tues.Tues. ______

Wed.Wed.Wed. ______

Thurs.Thurs.Thurs. ______

Fri. ______

*Please note the semesters you will be attending and are interested in having your child attend:

______

Note we close at 12:30pm on Fridays.

(There is NO guarantee you will receive your requested schedule. We do make every attempt to accommodate your request.)

Butte College Child Development Center

Enrollment Application

Please mark all boxes that apply to your family

Butte College Child Development Center

Enrollment Application

Pell Grant Recipient

Butte College Student

*Income Eligible (circle family size and income on chart below)

Receiving Subsidized Child Care(Valley Oaks, Calworks, EOPS)

Butte College Employee

Community Member

Veteran

Foster Youth

Registered with Disabled Student Services and Programs (DSPS)

Not Eligible for Pell Grant

*(circle family size)(circle income)

Number in householdYearly income

Family Size 2014 Income
1 $16,755
2 $22,695
3 $28,635
4 $34,575
5 $40,515
6 $46,455
7 $52,385
8 $58,335
Each Add'l Family Member $ 5,940

Butte College Child Development Center

Enrollment Application

Household Status: (Please indicate for each adult in household.)

Single Dependent Female

Single Dependent Male

Single Female – Head of Household

Single Male – Head of Household

Married Female

Married Male

Race:

Pacific Islander

Black

Asian

White

Hispanic

Native American

Biracial/Multi

Other

Date received: ______

May email to or drop-off at the center