Self-Pay Childcare Application

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Parent Information

Type of Parent/Guardian

Mother

Father

Stepmotherfather

Guardian

FosterParent

In Home?

Yes

First Name*

Last Name*

Email Address*

Spoken Language*

Telephone Number*

Street Address*

City*

Zip Code*

Are you working?

Yes

Employer

Are you a student?

Yes

Name of School

Child Information

Last Name of Child 1*

First Name of Child 1*

Birth Date of Child 1

Additional Children

Last Name of Child 2

First Name of Child 2

Birth Date of Child 2

Last Name of Child 3

First Name of Child 3

Birth Date of Child 3

Last Name of Child 4

First Name of Child 4

Birth Date of Child 4

Names and birthdates of other children in the home under the age of 18 who will not be receiving childcare/preschool services

I understand that it is my responsibility to notify AHC Childrens Lab School of any changes to the information on this application. Failure to report changes may be cause for removal of this application from the eligibility list. I agree that the information provided above is accurate and may be shared with other agencies in helping me receive childcare services.

IAccept

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Santa Maria Campus

Lompoc Valley Center

College Information

Community Interests

Student Services

Resources

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Student Tutoring and Research

Apply and Register

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Cashier Services

Hancock Promise

Self-Pay Childcare Application