* Required


Shasta County Childcare Application

Parent or Guardian Information

Include yourself ​​​​​
Ex: 555-555-5555​​​​​​​​​
Ex: 555-555-5555​​​​​​​​​
Ex: 555-555-5555​​​​​​
Email required for confirmation information​​.​​​​​​​​​​
If yes, you may qualify for a CalWorks funded program.​​​​​​​

If yes, you may qualify for a CalWorks funded program.​​​​​​​​​​

Family Income: Please select the source and note the total monthly amounts for both adults listed in the above section.

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.

Comments/Questions/Important Information​​​​​​​​​​