Community Child Care Council of Santa Clara County, Inc : I am a Parent : Needing Help Paying for Child Care : 4C CEL Application

4C CEL Application

The 4C Centralized Eligibility List (4C CEL) is access to free or low cost child care and preschool programs in Santa Clara County.

The 4C Council operates a countywide list of income-eligible families that need child care financial assistance. This is a free service that connects families to over 170 child care locations that receive funding from the California Department of Education to help low-to moderate-income families in their area.

To add your name to 4C CEL, print out and complete a 4C CEL application in the language of your choice, then send it to 4Cs at:

Community Child Care Council of Santa Clara County
2515 N. First St.
San Jose, CA 95131

Applicants should update their status on 4C CEL every three months by calling 408-487-0749. Due to the high demand for subsidized child care in Santa Clara county, there is no guarantee that everyone who applies will receive assistance.

Or, instead of printing and mailing your application, you may fill out the 4C CEL application questions below and submit them online. Please fill out ALL fields; if a field does not apply to you, please type N/A for that field.

Primary Parent

Primary Parent First Name *REQUIRED*

Primary Parent Last Name *REQUIRED*

Relationship to Child *REQUIRED*

Parent
Grandparent
Foster Parent
Legal Guardian

Other *REQUIRED*

Preferred Zip Codes - 1 *REQUIRED*

Preferred Zip Codes - 2 *REQUIRED*

Preferred Zip Codes - 3 *REQUIRED*

Current Address *REQUIRED*

Apartment/Unit *REQUIRED*

County *REQUIRED*

City *REQUIRED*

State *REQUIRED*

Zip Code *REQUIRED*

Home Phone *REQUIRED*

Cell Phone *REQUIRED*

Work Phone *REQUIRED*

Email *REQUIRED*

Language *REQUIRED*

Ethnicity *REQUIRED*

Family Size (include parents & children) *REQUIRED*

Date of Birth *REQUIRED*

Secondary Parent

Living in the home? *REQUIRED*

Secondary Parent First Name *REQUIRED*

Secondary Parent Last Name *REQUIRED*

Email *REQUIRED*

Date of Birth *REQUIRED*

Cell Phone *REQUIRED*

Work Phone *REQUIRED*

Language *REQUIRED*

Family Information

Characteristics (check all that apply) *REQUIRED*

Child Protective Services
Teen Parent
Seasonal Migrant Worker
Not Applicable

Other *REQUIRED*

Housing (check all that apply) *REQUIRED*

Currently homeless
Living in a Shelter
None

Are you a Community College or University student? *REQUIRED*

If yes, name of school *REQUIRED*

Reason for Care

Primary Parent *REQUIRED*

If working, work zip code *REQUIRED*

If attending school, school zip code *REQUIRED*

Secondary Parent *REQUIRED*

If working, work zip code *REQUIRED*

If attending school, school zip code *REQUIRED*

Living in the home? *REQUIRED*

Monthy Income: Primary Parent

Totaly Monthly Wage *REQUIRED*

Paid *REQUIRED*

Monthly
Bi-weekly
Weekly

Hours & Wage

Hours per week *REQUIRED*

$ per hour *REQUIRED*

Child Support *REQUIRED*

Spousal Support *REQUIRED*

Cash Aid or Foster Payment *REQUIRED*

State Disability Insurance (SDI) *REQUIRED*

Supplemental Security Income (SSI) *REQUIRED*

Other Income (Type) *REQUIRED*

Amount *REQUIRED*

Monthly Income: Secondary Parent

Living in the home? *REQUIRED*

Total Monthly Wage *REQUIRED*

Paid *REQUIRED*

Monthly
Bi-weekly
Weekly

Hours & Wage

Hours per week *REQUIRED*

$ per hour *REQUIRED*

Child Support *REQUIRED*

Spousal Support *REQUIRED*

Cash Aid or Foster Payment *REQUIRED*

State Disability Insurance (SDI) *REQUIRED*

Supplemental Security Income (SSI) *REQUIRED*

Other Income (Type) *REQUIRED*

Amount *REQUIRED*

Eligibility Assessment

Are you currently receiving child care/preschool assistance for your child(ren)? *REQUIRED*

Yes

No

If yes, name of program *REQUIRED*

Have you received Cash Aid (Welfare/TANF/AFDC) within the last 2 years? *REQUIRED*

Yes

No

If yes, date last received *REQUIRED*

If yes, provide your Case Number *REQUIRED*

Are you currently participating in CalWORKs? *REQUIRED*

Child 1

Name *REQUIRED*

School *REQUIRED*

School District *REQUIRED*

Date of Birth *REQUIRED*

Special Needs? *REQUIRED*

Yes

No

If yes

IEP

IFSP

Please explain *REQUIRED*

Schedule of Care *REQUIRED*

(F/T) Full time

(P/T) Part time

Evening

Weekend

Variable

Overnight

Preferred Child Care Center/Preschool *REQUIRED*

Program *REQUIRED*

Preferred type of child care setting/arrangement *REQUIRED*

Center

Licensed Family Home

Relative/Friend

Currently Enrolled? *REQUIRED*

Yes

No

If yes, what program? *REQUIRED*

Reason for re-applying *REQUIRED*

Child 2

Name *REQUIRED*

School *REQUIRED*

School District *REQUIRED*

Date of Birth *REQUIRED*

Special Needs? *REQUIRED*

Yes

No

If yes

IEP

IFSP

Please explain *REQUIRED*

Schedule of Care *REQUIRED*

(F/T) Full time

(P/T) Part time

Evening

Weekend

Variable

Overnight

Preferred Child Care Center/Preschool *REQUIRED*

Program *REQUIRED*

Preferred type of child care setting/arrangement *REQUIRED*

Center

Licensed Family Home

Relative/Friend

Currently Enrolled? *REQUIRED*

Yes

No

If yes, what program? *REQUIRED*

Reason for re-applying *REQUIRED*

Child 3

Name *REQUIRED*

School *REQUIRED*

School District *REQUIRED*

Date of Birth *REQUIRED*

Special Needs? *REQUIRED*

Yes

No

If yes

IEP

IFSP

Please explain *REQUIRED*

Schedule of Care *REQUIRED*

(F/T) Full time

(P/T) Part time

Evening

Weekend

Variable

Overnight

Preferred Child Care Center/Preschool *REQUIRED*

Program *REQUIRED*

Preferred type of child care setting/arrangement *REQUIRED*

Center

Licensed Family Home

Relative/Friend

Currently Enrolled? *REQUIRED*

Yes

No

If yes, what program? *REQUIRED*

Reason for re-applying *REQUIRED*

Child 4

Name *REQUIRED*

School *REQUIRED*

School District *REQUIRED*

Date of Birth *REQUIRED*

Special Needs? *REQUIRED*

Yes

No

If yes

IEP

IFSP

Please explain *REQUIRED*

Schedule of Care *REQUIRED*

(F/T) Full time

(P/T) Part time

Evening

Weekend

Variable

Overnight

Preferred Child Care Center/Preschool *REQUIRED*

Program *REQUIRED*

Preferred type of child care setting/arrangement *REQUIRED*

Center

Licensed Family Home

Relative/Friend

Currently Enrolled? *REQUIRED*

Yes

No

If yes, what program? *REQUIRED*

Reason for re-applying *REQUIRED*

List children who DO NOT need care

Name *REQUIRED*

Date of Birth *REQUIRED*

If already enrolled, program *REQUIRED*

Name *REQUIRED*

Date of Birth *REQUIRED*

If already enrolled, program *REQUIRED*

Name *REQUIRED*

Date of Birth *REQUIRED*

If already enrolled, program *REQUIRED*

Application Consent

By checking the box below you acknowledge and grant permission for your application to be shared among participating agencies.

- I declare that the above information is complete and true to the best of my knowledge.

- I understand my eligibility is based upon information given here and that documentation will be required prior to enrollment.

- In order to remain active on the CEL, I must take immediate action to inform 4Cs of any changes to my address, phone number or income.

- This application is valid for 3 months, however I understand that if I do not update this application within 3 months, my name will be removed
from the list.

Questions? Call 408-487-0749.

Do you accept *REQUIRED*

I accept

150 River Oaks Parkway, Suite F-1 | San Jose, CA 95134 | Phone: (408) 487-0747 | Fax: (408) 487-0762

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