Nihonmachi Little Friends | Enrollment | Application Form: Preschool Childcare

For Private and State-Subsidized Families

Application Instructions:

Please print, complete, sign (original signatures are required) and mail this form to NLF along with a $35.00 application fee. (Families applying for a state subsidized opening are not required to pay the application fee.) Application fees are non-refundable and tax-deductible. However, the fee does not guarantee your child's enrollment. Mail completed and signed forms with a check in the amount of $35.00 made payable to "Nihonmachi Little Friends" or "N.L.F." to the following address:

Nihonmachi Little Friends
Attn: Enrollment
2031 Bush Street
San Francisco, CA 94115

Or you may request materials be sent to you by mail.

Child's Name (Last, First, Middle) and birthdate:

**(Please list all children in the family unit and their dates of birth)

Number of
Family Members:

Type of Family: ( Mark an "x" next to one:)

___ Single-Parent Family and indicate: ( _____ Mother or _____ Father)

___ Two-Parent Family

Mother's Information (or guardian):

Name:

Address:

City/State/Zip:

Home Phone:

Employer/School:

Address:

Position:

Days/hours:

Work Phone:

Father's Information (or guardian):

Name:

Address:

City/State/Zip:

Home Phone:

Employer/School:

Address:

Position:

Days/hours:

Work Phone:

Other members in the family unit:

Name and relationship
to child:

Need:

I/we are applying for childcare services because:

If desired, indicate which program you prefer: _____ Bush _____ Sutter

Indicate type of program: _____ full-time _____ part-time

Income resources of family: This information is required for all families requesting state-subsidized childcare OR private families requesting the private sliding fee schedule. Income must be verified at time of enrollment. For families with undisclosed income, the maximum private fees will apply.

Please report your total gross monthly family income for each item requested:

Money wages or salary:	$
Net income from self-employment	$
Social Security benefits	$
Dividends, interest (on savings or bonds), income from estates or trusts, net rental income or royalties	$
Public Assistance or welfare	$
Pensions and annuities	$
Unemployment compensation	$
Worker's Compensation	$
Alimony and/or child support	$
Veteran's pensions	$
Other (please specify)	$
Gross Monthly Income:	$

I affirm that to the best of my knowledge and belief, the statements in this application are true. I understand that I have the right to appeal the denial of my request for services to the executive board of the agency.

Signature:

Relationship to child:

Date:

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		2031 Bush Street San Francisco, CA 94115 (415) 922-8898 nlfchildcare@yahoo.com