Butte College Child Development Center

Butte College Child Development Center Enrollment Application Parent Information *Parent 1# Name ______

*Mailing Address______Street City State Zip Code

Phone ______*Cell Phone______

*Email______*Butte College ID #______

Parent 2# Name ______

Mailing Address______Street City State Zip Code

Phone ______Cell Phone______

Email______Butte College ID #______Child(ren) Information *Childs Name ______*Birthday ______F or M Childs Name ______Birthday ______F or M Childcare Needs Please Check All That Apply Full Day A.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. Butte College Child Development Center Enrollment Application (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

 Pell Grant Recipient  Registered with Disabled Student Services and Programs (DSPS)  Butte College Student  Not Eligible for Pell Grant

*(circle family size) (circle income)  *Income Eligible (circle family size and Number in household Yearly income income on chart below) Family Size 2014 Income  Receiving Subsidized Child Care (Valley 1 $16,755 Oaks, Calworks, EOPS) 2 $22,695  Butte College Employee 3 $28,635 4 $34,575  Community Member 5 $40,515 6 $46,455  Veteran 7 $52,385  Foster Youth 8 $58,335 Each Add'l Family Member $ 5,940

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: ______Butte College Child Development Center Enrollment Application

May email to [email protected] or drop-off at the center