School Age Program - Waitlist Form

Serving the Community
		Senior Programs Staying active and healthy in the community

		Child Welfare Ensuring the wellbeing of every child

		Early Learning Preparing our children for the future

		Family & Community Impacting communities through the family

		Children and Youth Services Fostering youth leadership
Find the program you're looking for:

Any parent/guardian of a child who may be enrolled in Casa Central School Age Program must meet the following requirements: He/She must be working, in employment/training, or in school for at least 25 hours/week and must meet IDHS household income eligibility guidelines. Any child who is to be enrolled in the School Age Program must be between the ages of 5-12 years, enrolled in school, and be able to function in a group environment.
Child's Information
*	Name:
*	Date of Birth:
*	Child's Age :
*	Family Size:
*	Address:
*	Apt #:
*	Zip Code:
	School Enrollment:
	Home Telephone :
	Gender:	Male	Female
	Grade
	Room #:
	Teacher's Name:
Are there any physical/health limitations that we should be aware of?				Yes	No
	If yes, explain:

Parent and/or Guardian's Information

Name:
Date of Birth :
Name of Employer or School:
Employer's or School's Telephone #:
Work or School Schedule:	From:		to:
Gross Income (before taxes):
Pay Schedule :		Weekly
		Bi-Weekly
		Twice Monthly

Parent and/or Guardian's Information

Name:
Date of Birth :
Name of Employer or School:
Employer's or School's Telephone #:
Work or School Schedule:	From:		to:
Gross Income (before taxes):
Pay Schedule :		Weekly
		Bi-Weekly
		Twice Monthly

Do either of you receive Public Aid or any other financial aid?		Yes	No
If yes, please provide:
	Type:
	Financial Amount:
	Case #:


Copyright © 2007 [Casa Central]. All rights reserved.	Home Programs CareersContactsDonate