*
Required
SCOE Preschool Eligibility Screening
In which county are you currently residing?*
Shasta
Tehama
Are you currently with another subsidized program?*
Yes
No
If yes, which ones?
What are your preschool needs?*
Full time
Part time
Full day preschool (1st choice)
*
required
Please Select…
Alta Mesa Full Day
Bella Vista Preschool #2 Full Day
Cypress Full Day
Columbia Preschool Full Day
Juniper #1 Full Day
Lassen View #26 Full Day
Shasta Meadows Distance Learning
Tree of Life Charter Full Day (Anderson)
Full day preschool (2nd choice)
*
required
Please Select…
Alta Mesa Full Day
Bella Vista Preschool #2 Full Day
Cypress Full Day
Columbia Preschool Full Day
Juniper #1 Full Day
Lassen View #26 Full Day
Shasta Meadows Distance Learning
Tree of Life Charter Full Day (Anderson)
Full day preschool (3rd choice)
Please Select…
Alta Mesa Full Day
Bella Vista Preschool #2 Full Day
Cypress Full Day
Columbia Preschool Full Day
Juniper #1 Full Day
Lassen View #26 Full Day
Shasta Meadows Distance Learning
Tree of Life Charter Full Day (Anderson)
Part day preschool (1st choice)
*
required
Please Select…
Bella Vista #1 AM
Bonny View AM
Buckeye #1 AM
Buckeye #2 PM
Buckeye Preschool #5 AM
Grand Oaks AM
Juniper #2 AM
Lassen View #25 AM
Little Hill, (Mountain Union) AM
Mistletoe AM
Mistletoe PM
North Cottonwood AM
Oak Seed (Oak Run) AM
Prairie AM
Shasta College Collaboration AM
Shasta Meadows #16 AM
Part day preschool (2nd choice)
*
required
Please Select…
Bella Vista #1 AM
Bonny View AM
Buckeye #1 AM
Buckeye #2 PM
Buckeye Preschool #5 AM
Grand Oaks AM
Juniper #2 AM
Lassen View #25 AM
Little Hill, (Mountain Union) AM
Mistletoe AM
Mistletoe PM
North Cottonwood AM
Oak Seed (Oak Run) AM
Prairie AM
Shasta College Collaboration AM
Shasta Meadows #16 AM
Part day preschool (3rd choice)
Please Select…
Bella Vista #1 AM
Bonny View AM
Buckeye #1 AM
Buckeye #2 PM
Buckeye Preschool #5 AM
Grand Oaks AM
Juniper #2 AM
Lassen View #25 AM
Little Hill, (Mountain Union) AM
Mistletoe AM
Mistletoe PM
North Cottonwood AM
Oak Seed (Oak Run) AM
Prairie AM
Shasta College Collaboration AM
Shasta Meadows #16 AM
Parent or Guardian Information
Relationship to child*
Parent
Guardian
Foster Parent
Other
Specify relationship to child
*
required
Primary language
*
required
Please Select…
English
Spanish
Other
Specify other language
*
required
Ethnicity
American Indian/Alaskian Native
Asian
Black/African American
Caucasian/Non-Hispanic
Hispanic/Latino
Native Hawaiin/Pacific Islander
Decline to state
Marital status*
Married
Single
Divorced
Separated
Family size
*
required
Include yourself
First name
*
required
Last name
*
required
DOB
*
required
(mm/dd/yyyy)
Address
*
required
City
*
required
Zip code
*
required
Home/message phone#
*
required
Ex: 555-555-5555
Work phone #
Ex: 555-555-5555
Cell phone #
Ex: 555-555-5555
If cell phone is listed, can we text you?
Yes
No
Email address
*
required
Email required for confirmation information.
Check all that apply for parent/guardian (only for full-time preschool)*
Actively Working
In School
Actively Seeking Work
Homeless
Seeking Permanent Housing
Incapacity/Unable to Work
Have you, parent or guardian, received cash aid in California within the last 2 years?*
Yes
No
If yes, which county?
*
required
Is there another adult in the home?*
Yes
No
Other adults in the home: relationship to child*
Parent
Guardian
Foster Parent
Other
Primary language
*
required
Please Select…
English
Spanish
Other
Specify other language
*
required
Ethnicity
American Indian/Alaskian Native
Asian
Black/African American
Caucasian/Non-Hispanic
Hispanic/Latino
Native Hawaiin/Pacific Islander
Decline to state
Specify relationship to child
*
required
First name
*
required
Last name
*
required
DOB
*
required
(mm/dd/yyyy)
Primary language
*
required
Please Select…
English
Spanish
Other
Home/message phone#
*
required
Work phone #
Cell phone #
If cell phone is listed, can we text you?
Yes
No
Email address
*
required
Check all that apply for other parent/guardian:*
Actively Working
In School
Seeking Work
Homeless
Seeking Permanent Housing
Incapacity/Unable to Work
Family Income: Please select the source and note the total monthly amounts for both adults listed in the above section.
Income source
Please Select…
Employment/Self Employment
Unemployment
Disability
TANF/Cash Aid
Foster Care
Other
Amount monthly (before taxes)
Income source
Please Select…
Employment/Self Employment
Disability
Foster Care
TANF/Cash Aid
Unemployment
Other
Amount monthly (before taxes)
Income source
Please Select…
Employment/Self Employment
Unemployment
Disability
TANF/Cash Aid
Foster Care
Other
Amount monthly (before taxes)
Income source
Please Select…
Employment/Self Employment
Unemployment
Disability
TANF/Cash Aid
Foster Care
Other
Amount monthly (before taxes)
Do you pay child support/alimony?*
Yes
No
If yes, how much per month (enter as a negative number)?
*
required
Total MONTHLY earnings before taxes
*
required
Include: Employment, Child Support, Disability, Unemployment, TANF, Foster Care, Child Support/Alimony.
Enter total gross monthly income
Children: Please list all children living in the home beginning with the youngest.
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
Is there another child living in the home?*
Yes
No
Child first name
*
required
Child last name
*
required
DOB
*
required
(mm/dd/yyyy)
Gender*
Male
Female
Has this child attended SCOE preschool before?*
Yes
No
Does this child have special needs?*
Yes
No
Special needs*
Individualized Education Program (IEP)
Individualized Family Service Plan (IFSP)
Other
Please specify special needs here:
Is there an open child protective services (CPS) case?*
Yes
No
If yes, list date & case number:
*
required
How did you hear about us?*
Flyer/Printed Material
School Site
Website
Radio
Social Media
Friend/Family
Other
Comments
Comments/Questions/Important Information
Please send a confirmation email to the address below*: