Subsidized Childcare Application

Please don't fill out this input box.

Parent Information

Type of Parent

Mother

Father

Step mother/father

Guardian

Foster Parent

In Home?

Yes

First Name

Last Name

Email Address*

Primary Language

Telephone Number

Street Address

City

Zip Code

Are you working?

Yes

Employer

Are you a student?

Yes

School

Which location do you prefer?

Santa Maria Campus

Lompoc Valley Center

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

Family Information

Family Size

Total Gross (Monthly) Household Income. Please enter monthly amount from all sources BEFORE any deductions:

Do you receive the Federal Pell Grant?

Yes

I understand that it is my responsibility to notify AHC Children's Center 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. *

Yes

I understand that this application will not be considered complete until I turn in my last 30 days of income, birth certificates for all children in my family, immunizations for the child(ren) I want to enroll and a copy of my school schedule, if applicable. I must bring all documentation to the children's center located on the Santa Maria Campus in Building I. *

Yes

AHC Student ID

College Information

Community Interests

Student Services

Resources

Programs and Degrees

Student Tutoring and Research

Apply and Register

Admissions and Records

Financial Aid

Cashier Services

Hancock Promise

Subsidized Childcare Application