1. No category

Lakeside Early Advantage Preschool
STATE PRESCHOOL
REGISTRATION FORMS
These forms must be completed as well as the All
Preschool Students Registration forms
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
Robyn Bowman-Preschool Director (619) 390-2391
REGISTRATION CHECK OFF LIST
Date Received
Birth Date
Child’s Name
st
Age as of September 1
All LEAP Programs
Birth Certificate
Immunization Record
LEAP Registration Form
LUSD Student Registration Form
Emergency Information Card
Parents’ Rights
Personal Rights
Consent for Emergency Medical Treatment
Internet and Photo Agreement
Child’s Preadmission Health History
Physician’s Report
Home Language Survey
LEAP State Program
-Income Calculation Worksheet
-Terms and Conditions
-Family Fee Chart
-Self-Declaration of Income
-Zero-Income (if needed)
-Single Parent Statement (if needed)
-Residency Verification Checklist
-Certification of Eligibility
-Childcare Data Collection Form
-Notice of Action
-Family Needs Form
-Free/Reduced Lunch Application
Copies of:
-One month current check stubs
-Two proofs of residency
-Birth Certificates of ALL children
(under 18)
-Current Immunization Record
CD-ICW INCOME CALCULATION WORK SHEET – CASH, WAGES, or SALARY
Parent A
•
•
•
•
Pay Periods
Parent B
Pay Periods
Twice-monthly pay cycles are usually 15 days or longer from the 1st - 15th and the 16th - 30/31st
Twice-monthly salaried wage stubs will often show 86.66 or 86.67 under the "hours" section
Every-2-weeks pay cycles are usually 14 days and begin on the same day of the week and end on the same day of the week per pay cycle
For migrant workers, monthly gross income is computed by averaging the total gross income received during the previous 12 months and is
NOT recalculated until the next annual recertification
• Select Appropriate Income Pay Cycle for Wage Calculations
Weekly: (52 pay periods annually):
A. $_______ + $________ + $________ + $________ = $_________ /4 = $________ (weekly average)
Weekly average $________ X 52 weeks /12months = $____________ gross monthly income
B. $_______ + $________ + $________ + $________ = $_________ /4 = $________ (weekly average)
Weekly average $________ X 52 weeks /12months = $____________ gross monthly income
Every two weeks (26 pay periods annually):
A. $________ + $________ = $________ /2 = $________ (Two week average)
Two week average $________ X 26 pay periods /12 months = $_________ gross monthly income
B. $________ + $________ = $________ /2 = $________ (Two week average)
Two week average $________ X 26 pay periods /12 months = $_________ gross monthly income
Twice monthly (24 pay periods annually):
A. $_________ + $_________ = $_________ gross monthly income
B. $_________ + $_________ = $_________ gross monthly income
Monthly: (12 pay periods annually):
A. $___________ gross monthly income
B. $___________ gross monthly income
Fluctuating: use for seasonal, migrant, agricultural, fluctuating
A. $__________ 12 months* worth of income / 12 = $ ___________ gross monthly income
B. $__________ 12 months* worth of income / 12 = $ ___________ gross monthly income
* Add all paychecks received in the prior 12 months.
Other Sources of Countable Income:
________ Public assistance
________ Disability/Unemployment
________ Workers Compensation
________ Spousal Support
________ Child Support
________ Survivor benefits
________ Retirement benefits
________ Dividends/Interest
________ Rental Income
________ Foster care grant
________ Financial assistance for child
________ Veterans pension
________ Annuity/Pension
________ Inheritance
________ Housing included in pay
________ Auto included in pay
________ Student loan living expenses
________ Insurance settlements
________ Net gain from property
________ Other income
________ Subtotal
________ GMI from column 1
________ Total Countable Income
California Department of Education
July 2012
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
Lindo Park Elementary School
12824 Lakeshore Drive, Lakeside, CA 92040
STATE PRESCHOOL PROGRAM
Terms & Conditions
Effective July 1, 2012, newly enacted California State law (Chapter 38, Statutes of 2012) requires that
families with children enrolled in part-day California State Preschool Programs be assessed a family fee
in accordance with current law. The amount of the family fee is assessed using a California Family Fee
Schedule and is based on the following factors: family income, family size, and children enrolled in
other programs that have assessed a family fee.
LUSD’s State Preschool program and classes are subject to availability. The District has the right to
discontinue these services at its discretion or if funding is discontinued.
FEES: Fee payments are due in full by the 1st of each month. Fees will not be prorated for
illness or vacations. Payment will be considered late if not paid by the 7th of the month.
Payments can be placed in the mailbox in your child’s classroom.
 Checks or money orders payable to: LUSD
 Payments by cash, place in envelope provided in the classroom.
 There is a returned check fee of $35.00 for each occurrence. After two returned checks,
all future payments must be made using money order, cashier’s check or cash.
PAST-DUE FEES: The Preschool Program will establish a reasonable plan for payment of past
due fees. Fees shall be considered delinquent when they are seven (7) calendar days in arrears.
A notification of delinquent fees is then generated.
If fees are delinquent:
 A Notice of Action (NOA) to terminate services shall be mailed or given to the parent. The
NOA shall state the total amount of unpaid fees, the fee rate, the period of delinquency, and
state that services shall be terminated 14 days from the date of the NOA unless all delinquent
fees are paid before that date or a repayment plan is established.
 A reasonable plan for payment may be established and approved by the program. This
approval is dependent upon past payment history and the amount of delinquent fees owed. In
addition to the delinquent fee payment, current preschool fees MUST be paid on time.
Preschool services shall continue, provided current fees are paid when due, and there is
compliance with the provisions of the repayment plan.
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
STATE PRESCHOOL
Family Fee Assessment
Student___________________________ Parents/Guardian____________________________
Effective July 1, 2012, California State law requires families with children enrolled in part-day
California State Preschool Programs be assessed a family fee. The amount of the family fee is
assessed using a California Family Fee Schedule and is based upon family income and family
size.
Income_____________
Family size__________
Daily fee____________
Your family fee for the first month of ___________for ______days of services is _________ and
is due prior to the first day of school.
All other fees are due no later than the 10th day of the month.
September
October
November
December
January
February
March
April
May
June
Number of Days
21
23
16
15
19
18
20
14
19
15
Fee
I agree to the above fee assessment and schedule. I have been provided with the State
Preschool fee policy.
Parent/Guardian Signature_______________________________ Date___________________
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
Lindo Park Elementary School, 12824 Lakeshore Drive, Lakeside, CA 92040
Preschool Director (619) 390-2391
Self Declaration of Income
Child’s Name:
I,
(year)
Last,
was $
First,
MI
Date of Birth:
Month/Day/Year
verify that my monthly gross income for the month of
,
.
I was paid in the following manner:
Employer/Company Name
The job(s) performed were:
Address
Work Days
Phone Number
(Circle Appropriate)
S M T W TH F S
S M T W TH F S
S M T W TH F S
S M T W TH F S
S M T W TH F S
S M T W TH F S
S M T W TH F S
Do you receive cash aid?  Yes  No If yes, please provide your nest month’s cash aid-Notice of Action.
Other Sources of Income
Check All
Overtime / Tips

Commission / Bonuses

Dividends, Interest

Public Assistance, TAMF

Unemployment

Disability

Workers’ Compensation

Alimony (Received)

Child Support (Receive)

Pensions

Other (do not include food stamps)

Monthly Income
I declare under penalty of perjury that the above information is true and correct to the best of my knowledge. I understand that the
information about my income may be reviewed by representatives of the State of California, the Federal Government, independent auditors, or
others as necessary for the administration of the program.
Signature of Parent/Guardian
Authorized Preschool Representative
Date
Preschool Title
Date Verified
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
Lindo Park Elementary School
12824 Lakeshore Dr, Lakeside, CA 92040
“Zero Income” Sworn Statement
Child’s name:
SWORN STATEMENT REGARDING: Please complete in your own words what your qualification
for consideration due to “Zero Income” are regarding registration into the LEAP State Preschool
Program.
I, (print name)
hereby swear or affirm that,
I declare under penalty of perjury that the information contained in this statement is true,
correct and complete. Failure to report correct information and ALL facts may result in
termination of preschool services.
Qualifying Parent Name (printed):
Signature - Qualifying Parent
Date Signed
Head of Household (different than above person) (printed):
Signature - Head of Household (must be different than qualifying parent)
Date Signed
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
Lindo Park Elementary School
12824 Lakeshore Dr,Lakeside, 92040
PRESCHOOL DIRECTOR (619) 390-2391
“Single Parent” Sworn Statement
Child’s name:
SWORN STATEMENT REGARDING: Please complete in your own words what your qualification
for consideration due to your “Single Parent” status are regarding registration into the LEAP
State Preschool Program.
I, (print name)
hereby swear or affirm that, I
am the only parent responsible for this child due to the following circumstances:
I declare under penalty of perjury that the information contained in this statement is true,
correct and complete. Failure to report correct information and ALL facts may result in
termination of preschool services.
Qualifying Parent Name (printed):
Signature - Qualifying Parent
Date Signed
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
Lindo Park Elementary School, 12824 Lakeshore Dr, Lakeside, CA 92040
Preschool Director (619) 390-2391
Residency Verification and Checklist
(Print Clearly)
1.
4.
I AM THE: (CHECK ONE)
o PARENT
NAME OF PERSON ESTABLISHING RESIDENCY
2. NAME OF CHILD OR CHILDREN:
o
FOSTER PARENT
o
LEGAL GUARDIAN
o
RELATIVE / CAREGIVER
o
OTHER
3.
PARENT NAME:
SCHOOL OR RESIDENCE:
NAME OF SCHOOL
5.
I AFFIRM THAT THE STUDEN(S) RESIDES AT THE FOLLOWING STREET ADDRESS:
STREET ADDRESS
6.
CITY
I,
APT NO. OR UNIT
STATE
ZIP CODE
, AFFIRM THAT THE ADULT AND STUDENTS LISTED ABOVE RESIDE AT MY RESIDENCE.
SIGNATURE
DATE
WARNING: DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ABOVE ARE INCORRECT, OR YOU WILL BE COMMITTING A
CRIME PUNISHABLE BY A FINE, IMPRISONMENT OR BOTH
SIGNATURE OF PERSON ESTABLISHING RESIDENCY
DATE
FALSIFICATION OF ANY INFORMATION OR DOCUMENTS, EITHER WRITTEN OR VERBAL, RELATIVE TO THIS VERIFICATON
PROCEDURE WILL RESULT IN REVOCATON OF ENROLLMENT
The Person establishing residency must present TWO (2) of the following “ORIGINAL” documents:
DEED TO HOME
MORTGAGE PAYMENT RECEIPTS OR COUPONS
MORTGAGE PAYMENT RECEIPTS OR COUPONS
PROPERTY TAX RECEIPT
CURRENT BILL FROM LOCAL UTILITY
COMPANY, INCLUDING CABLE TV
 RECEIPT FOR DEPOSIT WITH LOCAL
UTILITY COMPANY, INCLUDING CABLE TV
 MILITARY ORDERS (BASE HOUSING OFFICE
WRITTEN VERIFICATION)





 DECLARATION OF TEMPORARY RESIDENCY
AFFIDAVITS FOR HOMELESS FAMILIES
 RENTAL AGREEMENT
 RENT RECEIPT
 BANK STATEMENT
 ANY OTHER LEGAL DOCUMENT(S) WHICH
ESTABLISHES HOME ADDRESS WITHIN
SCHOOL BOUNDARIES
 OTHER
The document(s) described in the box as checked above was presented by the person identified in #1 above verifying the student’s
residency. The student’s registration address matches the address listed in the residency verification document.
VERIFYING SCHOOL OFFICIAL
DATE
Confidential Application for
Child Development Services and
Certification of Eligibility
Agency Name:
Family Identification/Case No.:
Initial Subsidized Service Date:
Type of Application: (Check one) Initial
Form CD 9600, Page 1, (REV 05/12)
Recertification
Note: State regulations require a formal application and certification for child development services. You will receive written notice of your eligibility no later than
30 days from the date of your signature on this form. Eligibility is determined on the basis of need for child development services and either CalWORKs status or
adjusted gross monthly income in relation to family size. This form must be completed by an agency representative in consultation with the family. Refer to the
instructions for the completion of this form.
Section I. Family Identification. If you are a single parent/caretaker, check this box: See Instructions, Section I.
Name of parent/caretaker (full name, including middle initial)
A
Social Security Number - parent A* (See
instructions.)
Gender
Phone no. (home)
Phone no. (work/school)
Name of parent/caretaker (full name, including middle initial)
B
Gender
Phone no. (home)
Phone no. (work/school)
Street address
City
State
FIPS code
Section II. Family Eligibility and Reason for Needing Service
A. Family Eligibility Status (Check as many as apply )
Protective services (attach
Income eligible (attach
documentation.)
documentation.)
X
Zip
Homeless (attach
documentation.)
Programs for the severely
handicapped)
B. Reason for Needing Service. Indicate all the reasons for needing care for each adult listed above. Enter “A” or “B” referring to parent/caretaker listed above.
Attach documentation. (This section does not apply to part-day state preschool programs or programs for severely handicapped.)
Reason for Needing Service
Parent/
Caretaker
Parent/
Caretaker
Reason for Needing Service
Parent/
Caretaker
Stages 1, 2, and 3 CalWORKs recipients only
Child referred for protective services because of
neglect, abuse, exploitation, or risk thereof
Education or training
CalWORKS activities
Parent/caretaker incapacitated because of medical or
psychiatric special needs
Actively seeking employment
Diversion
Working
Seeking permanent housing
Date parent became
ineligible for aid:
Date: ____________
Record date of entry into each stage:
Stage 1________ Stage 2________ Stage 3________
C. Employment/Training Information. Must be completed for each adult listed in Section I above to document need on the basis of employment or training.
(Attach documentation.)
Parent/
Caretaker
Employer/School
Street Address
City
Zip
Sat.
Sun.
City
Zip
Sat.
Sun.
A
A
Days and working/
training hours:
From:
To:
Mon.
Tues.
Wed.
Employer/School
Parent/
Caretaker
Thurs.
Fri.
Street Address
B
B
Days and working/
training hours:
From:
To:
Mon.
Tues.
Wed.
Thurs.
Fri.
Section III. Family Adjusted Gross Monthly Income and Size
A. Family monthly income. The family's adjusted monthly income from all sources (Attach verification and documentation.): $_______________
B. Family income sources (Check all that apply. Do not count the gray shaded areas in Section III. A above.) Black shaded boxes for CalWORKs recipients only.
C. Family size (See “Funding Terms and Conditions” for instructions on calculating family size.): __________________
Employment, including self-employment
Other federal cash income programs (such as SSI)
Child support
Housing voucher or cash assistance
Cash or other assistance under Title IV of the Social Security Act (TANF)
Assistance under the Food Stamps Act of 1977
State-only alien and two-parent programs for CalWORKs recipients
Other
Section III B is for federal data collection purposes only and does not need to be completed before the provision of child care services.
Confidential Application for
Child Development Services and
Certification of Eligibility
CD 9600 Page 2 (REV. 05/12)
Section IV. Data on Children. List all children residing in the home and counted in the family size.
Complete only for children served by your agency
(2)
(3)
(4)
Gender
Birth Date
Adjustment
Factor
Code
of Child
M
Including Middle
F
MM/DD/YYYY
Initial
(5)
For children enrolled in more than one program or site, use additional lines as needed
(7)
(8)
Native
Language
Ethnicity
(1)
Full Name
(6)
Race
Complete for all children residing in the home
Language
Code
(9)
Program
Code
Is child
limited
English
proficient?
(10)
Hours of Care per Day
Type of Care
Code
CSPP
04
S
M
T
W
TH
F
3
3
3
3
3
SAT
SUN
Provider/site name:
Lakeside Union Elementary School District
V
S
Provider/site name:
V
S
Provider/site name:
V
S
Provider/site name:
V
S
Provider/site name:
V
S
Provider/site name:
V
Section V. Certification and Signature of Parent/Caretaker.
1.
2.
3.
4.
I declare under penalty of perjury that the above information is true and correct to
the best of my knowledge.
I will notify the agency immediately if there is any change in my income, family size,
residence, employment, or reason for needing child development services.
I understand that the information about my eligibility may be reviewed by
representatives of the state of California, the federal government, independent
auditors, or others as necessary for the administration of the program.
I understand that if the agency denies this application for services, I have the right to
appeal.
Signature
5.
I understand that I must renew my eligibility at least once a year (at least once
every six months for protective services children). I further understand that if I
do not renew my eligibility, I will no longer be eligible for subsidized child care
services for my child.
I understand that I will receive a notice of approval or disapproval of my
application within 30 days from the date I sign this form.
I understand that this certification is not complete until all documentation is
submitted and this form has been reviewed, signed, and dated by an agency
representative and signed and dated by me.
6.
7.
Relationship to Child:
Date
Foster Parent
Parent
Grandparent
Guardian
Other: Please describe _________________
Section VI. Family Fee (See fee schedule.).
Type of Fee
Full Time
A. Daily fee (if any)
X
B. Hourly fee (if any)
X
Part Time
X
Section VII. For Office Use Only. (Certification is not complete until eligibility is reviewed, signed, and dated by an agency representative.)
Date Notice of Action Sent
Eligibility Status
Accepted
Denied
Signature of Authorized Agency Representative
(Attach copy)
Date Notice of Action Given
(Attach copy)
First date of subsidized
service
Last date of
enrollment
Title
Telephone number
Date
Telephone number
Date
Preschool Teacher
Signature of Supervisor (Optional)
Title
Preschool Director
CD 9600 (Rev. 05/12)
Instructions Page 1
Instructions for Completing Form CD 9600:
Confidential Application for Child Development Services and Certification of Eligibility
Form CD 9600 (or documentation containing the same information) must be completed and signed by the parent and an agency representative before the child
enters the child development program. The certification must be renewed at least once a year (at least once every six months for protective service's children).
Families must notify the agency immediately if there are changes in their family status, family size, income, residence, or need for child care. If such changes occur,
agency staff must update the certification. Notification of changes, except residence, are not required for part-day state preschool or severely handicapped
programs. All certification forms and documentation must be maintained in the family file.
Social Security Number (SSN) Collection Consent
Form CD 9600A, the Child Care Data Collection/Privacy Notice and Consent
Form, must be completed and signed by all heads of households in all CDEfunded programs. If the head of household gives consent to use their SSN,
the SSN should be inserted on the CD 9600. If the head of household does not
give consent, leave the SSN space blank on the CD 9600. In "family of one"
situations the SSN will not be collected; therefore, completion of the CD 9600A
is not required. When completed, attach the CD 9600A to the CD 9600.
* The social security number is to be listed only for heads of households
who have given consent on form CD 9600A. In all cases, a CD 9600A
must be completed and signed by the head of household and
attached to the CD 9600. In "family of one" situations, no SSN is
required and no CD 9600A will be completed.
Agency Name: Insert the name of the agency providing or funding child care
services in this space.
Family Identification/Case Number: This is an optional field and can be
used if the agency assigns an identification or case number to each family.
Initial Subsidized Service Date: This is the earliest month and year that the
child(ren), as listed on this CD 9600, first started receiving subsidized child
care services from your agency. Every CD 9600 must have a month and
year entered in this field. This information is for data reporting purposes. If
there is a break of three months or more, enter the month child care
resumed. If there is a break of less than three months (vacation, for
example), enter the original date assistance began, not the date it resumed.
Type of Application: Check the box after "Initial" if this is the first application
taken by the agency named on this CD 9600. Check the box after
"Recertification" if this is the second or later application taken by the agency
listed on this CD 9600.
Section I. Family Identification
Note: If family size includes more than two adults, complete Sections I, II,
and III of a second CD 9600 and attach it to the complete CD 9600. You
may also use a second CD 9600 to record additional employers or
training institutions for the parents listed under A and B in Section I.
If the child lives with only one parent/caretaker who is legally/financially
responsible for the child, check the box on the line next to Section I.
A.
Information on parent/caretaker A. For the first adult living in the same
household as the child(ren), complete all items in Section I A, including
address information. For the purposes of these instructions and the
certification of eligibility, a parent/caretaker shall be a person who has
responsibility for the child. Thus, “parent/caretaker” could refer, for
example, to a biological parent, a stepparent, a grandparent, a foster or
adoptive parent, or a legal guardian. For SSN information, see above.
FIPS Code. See the “FIPS Codes” section on page three of these instructions
to determine the FIPS Code that identifies the state and county where the
parent/caretaker lives.
B. Information on parent/caretaker B. If a second parent/caretaker lives in
the same household as the child and is included in the calculation of
family size, complete all items in Section I B.
Section II. Family Eligibility and Reason for Needing Service
A.
Family eligibility status. Check all eligibility categories for which the
family qualifies.
B.
Reason for needing service. For each parent/caretaker or other adult
included in the family size, note with an “A” or “B” all of the reasons for
needing services and attach the appropriate documentation. Identify the
main reason for needing service with an asterisk if there is more than one
reason. Do not complete this section for part-day state preschool or
severally handicapped.
CalWORKs recipients only: This box is to be completed for all CalWORKs
recipients receiving services in Stages I, 2, or 3.
• If a parent/caretaker is completing CalWORKs activities, enter “A” and/or
“B” in the box labeled “CalWORKs Activities."
• If a parent/caretaker has received a diversion payment, enter “A” and/or
“B” in the box labeled “Diversion.”
• In the box labeled “Record date of entry into each stage,” enter the initial
date of entry into each stage.
• For Stage I or II families no longer eligible for CalWORKs aid, enter
the date the parent became ineligible for aid in the box labeled
“Date parent became ineligible for aid.”
C.
Employment/training information. For each parent/caretaker, enter
the name and address of the employer or the institution of training or
education, as appropriate. Do not complete this section for part-day state
preschool or programs for severally handicapped.
Days and working/training hours. Note the beginning and ending hours for
each day that the parent is employed or in a training program.
Section III. Family Adjusted Gross Monthly Income and Size
A.
Family monthly income. Enter the family’s total adjusted gross monthly
income from all sources. All income must be verified.
B.
Family income sources. Check each box to identify all sources of
family income. These include sources of income that are not counted for
eligibility determinations.
The black shaded boxes are to be completed for CalWORKs recipients
only. County welfare departments will identify whether a CalWORKs
recipient is receiving CalWORKs benefits under the State-only alien
program or the state-only two-parent program. These two programs
count toward Temporary Assistance to Needy Families Maintenance of
Effort.
The gray shaded boxes are not to be counted in the family’s total
adjusted monthly income.
•
•
CD 9600 (Rev. 05/12)
Instructions Page 2
Instructions for Completing Form CD 9600:
Confidential Application for Child Development Services and Certification of Eligibility
Section III. Family Adjusted Gross Monthly Income and Size
(Continued)
10. Hours of care per day. Enter the amount of child
development services needed each day in column 9. Use the
upper line (marked “S”) to indicate the amount of care needed
during the school session; use the lower line (marked “V”) to
indicate the amount of time needed during vacations. For
preschool-age children, use only the upper line to record the
amount of care needed.
Section III B is for federal data collection purposes and does
not need to be completed before the provision of child care
services.
C.
Family Size. Enter the total family size, including (1) all
parent(s)/caretaker(s) listed on the CD 9600; (2) all children
named in Section V; (3) any adult listed on a second CD 9600;
and (4) any children listed on a second CD 9600.
Note: For families whose schedules vary, enter the average
enrollment hours needed for child care services each day.
Attach a detailed schedule to reflect this average enrollment
over a one-month period.
Section IV. Data on Children
Note: Complete columns 1 and 3 of this section for all children
eighteen and under residing in the household. If needed, use a
second CD 9600 to record more children.
1.
Name of child. List all children residing in the in the household,
eighteen and under, related by blood, marriage, or adoption to the
parent(s)/caretaker(s) of the child(ren) being served.
2.
Gender. Check the appropriate box in column 2 for each child
receiving care through this certification.
3.
Birth date. In column 3 enter the birth dates of all children listed in
column 1 following this format: month/day/year.
4.
Adjustment factor code. See the “Adjustment Factor Codes”
section in these instructions to determine the adjustment factor
code that should be entered in column 4. If no adjustment factor is
used, leave this box blank.
5.
Ethnicity. Enter a “Y” if the child is Hispanic or Latino. Otherwise,
enter an “N”.
6.
Race: See the “Race Codes” section in these instructions to
determine the race code(s) that should be entered in column 6. At
least one code must be entered, but you may enter all codes that
apply for each child.
7.
Native language. See the “Native Language Codes” section in
these instructions to determine the native language code that
should be entered in column 7. Use only those native language
codes provided. Report the child's primary language. Indicate
whether or not the child is limited English proficient with a check
mark in column 7. This column must be completed if you claim LEP
reimbursement for this child.
8.
Program code. See the “Program Codes” section in these
instructions to determine the program code(s) that should be
entered in column 8. Enter one code per line for each child
receiving child care services through this certification. If the
child(ren) is enrolled in more than one program or with more than
one provider, use additional lines to record this information in
columns 8 and 9 for each child.
9.
Type of care and relationship to child. See the “Type of Care
Codes” section in these instructions to determine the type of care
code(s) that should be entered in column 9. Enter the provider or
site name in the space provided.
Section V. Certification and Signature of Parent/Caretaker
Read and explain the conditions of eligibility and need to the
parent/caretaker and make sure he or she understands them before
signing the application. Before the agency representative signs the
form, the parent/caretaker completing the application must sign and
date the form and indicate his or her relationship to the child.
Section VI. Family Fee
A.
Daily fee. Consult the fee schedule issued by the Child
Development Division and enter the correct fee for the family size
(Section III C), family income (Section III A), and amount of care
required (Section IV, column 10).
B.
Hourly Fee. If you do not collect hourly fees, leave these boxes
blank.
Section VII. For Office Use Only
The agency representative must complete the items in this
section. The certification is not complete until it is signed and
dated by the agency representative.
The “Signature of Supervisor” is an optional field and is not
required.
Completing the Form
Follow these procedures once you have completed the family’s
certification:
A.
File the completed form in the family file.
B.
If the family has a new or updated certification, add it to the
family file. Do not remove the earlier applications.
CD 9600 (Rev. 05/12)
Instructions Page 3
Instructions for Completing Form CD 9600:
Confidential Application for Child Development Services and Certification of Eligibility
Section I. Family Identification
Federal Information Processing Standards (FIPS) Codes
The FIPS code consists of a state code, which is a two-digit number,
and a county code, which is a three-digit number. The codes are
California - 06, Arizona - 04, Nevada - 32 and Oregon - 41.
California County Codes are as follows:
001
003
005
007
009
011
013
015
017
019
021
023
025
027
029
031
033
035
037
039
Alameda
Alpine
Amador
Butte
Calaveras
Colusa
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
041
043
045
047
049
051
053
055
057
059
061
063
065
067
069
071
Marin
Mariposa
Mendocino
Merced
Modoc
Mono
Monterey
Napa
Nevada
Orange
Placer
Plumas
Riverside
Sacramento
San Benito
San Bernardino
073 San Diego
075 San Francisco
077 San Joaquin
079 San Luis Obispo
081
083
085
087
089
091
093
095
097
099
101
103
105
107
109
111
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sutter
Tehama
Trinity
Tulare
Tuolumne
Ventura
113 Yolo
115 Yuba
If the family resides outside California, list the state code only.
Section IV. Data on Children
Column 4: Adjustment Factor Codes
21 Infant
22 Exceptional needs
23 Child protective services
24 Severely disabled
25 Limited English proficient (LEP)
27 Toddler
Column 7 Native Language Codes (Continued)
39
14
15
00
16
17
18
19
43
21
22
23
Chaozhou
Croatian
Dutch
English
Farsi (Persian)
French
German
Greek
Gujarati
Hebrew
Hindi
Hmong
English
47 Lahu
07 Mandarin
(Putonghua)
48 Marshallese
44 Mien
49 Mixteco
88 Native American
Languages
40 Pashto
05 Pilipino
(Tagalog)
41 Polish
2
4
For current contract program codes and contract prefixes, access the
Child Care and Development Contract Program Types Web page at
http://www.cde.ca.gov/sp/cd/ci/ccdprogramtypes.asp.
Column 9: Type of Care Codes
02
03
04
05
06
07
08
Licensed family child care home
Licensed large family child care home
Licensed center-based care
License-exempt in-home (child’s) care provided by a relative
License-exempt in-home (child’s) care provided by a nonrelative
License-exempt care provided outside child’s home by a relative
License-exempt care provided outside child’s home by a
nonrelative
11 License-exempt center-based care
Asian
Native Hawaiian or other
Pacific Islander
Column 7: Native Language Codes
11
12
42
13
03
36
Arabic
Armenian
Assyrian
Burmese
Cantonese
Cebuano
(Visayan)
54 Chaldean
20 Chamarro
(Guamanian)
24
25
26
27
08
09
Hungarian
Ilocano
Indonesian
Italian
Japanese
Khmer
(Cambodian)
50 Khmu
04 Korean
51 Kurdish
06
28
29
45
30
31
52
01
46
32
Portuguese
Punjabi
Russian
Rumanian
Samoan
Serbian
Serbo-Croatian
Spanish
Taiwanese
Thai
Toishanese
Turkish
Ukrainian
Urdu
Vietnamese
Other
Languages
of China
66 Other
Languages of
the Philippines
99 Other non-
Column 8: Program Codes (Contract Prefix)
Column 6: Race Codes
1 American Indian or Alaskan Native
3 Black or African American
5 Caucasian
53
33
38
35
02
55
California Dept of Education May 2012
CALIFORNIA DEPARTMENT OF EDUCATION
Form CD 9600A, (Rev. 01/04)
Child Care Data Collection
Privacy Notice and Consent Form
The United States Department of Health and Human Services (HHS) is gathering information about
families who receive child care assistance. The information will be reported to the California
Department of Education (CDE) and then to HHS. The information will be used for research on the
status of child care in the United States and will provide valuable data to persons developing child
care programs and policies at the state, local, and national levels.
All the information HHS receives about your family and other families will be summed up and
reported to Congress every two years. No person or family will be individually identified in reports
made to Congress, the Legislature, other governmental agencies, or the public.
To ensure that children and families receiving child care services are counted only once, HHS and
CDE are requesting the Social Security Number of the head of the family unit receiving child care
assistance. If you do not wish to give your Social Security Number for this purpose, you may still
receive child care assistance. Social Security Numbers will help CDE meet HHS reporting requests
and state requirements for program statistics. Authority to ask for your Social Security Number for
this purpose is stated in Section 98.71(a)(13) of Title 45 of the Code of Federal Regulations,
Education Code Section 8261.5, and Section 18070 of Title 5 of the California Code of Regulations.
Your decision to provide your Social Security Number is voluntary.
I have been informed of the way my Social Security Number will be used. I
understand that if I do not wish to give my number, I can still receive child care
assistance.
YES, my Social Security Number may be used: _______-_____-_______
NO, I do not wish to give my Social Security Number for this purpose.
______________________________________
Signature of the Head of Household
____________________
Date
______________________________________
Type or Print Name
You have the right to access records containing your personal information. For information about this system of records, contact the
California Department of Education, Child Development Division, 1430 N Street, Sacramento, CA 95814; telephone (916) 4451907.
California Department of Education
Early Education and Support Division
NOTICE OF ACTION
Form CD-7617, (Rev. 8/11)
1. Notice of Action (Complete Either 1.A. or 1.B.)
1.A. Application for Services
Services Denied
1.B. Recipient of Services
Change in Service
Termination of Service
Termination of Service for Delinquent Fees
If appealed, appeal is due by:
Effective Date of Action:
Services Approved to Begin:
Date
Date
(Note: Appeal Instructions are on reverse side.)
If appealed, date appeal is due by:
Date Notice Given or Mailed:
2. Distribution of Notice
Notice Given to Parent/Caretaker
Notice Mailed:
First Class
Other: ________________________
Recipient's Initials:
Tracking No.
3. Parent/Caretaker Information
Parent/Caretaker A
Address
Parent/Caretaker B
City
Zip
Telephone
4. Approved Child Care Services (Complete all information for each child approved for services.)
Name(s) of Child(ren) Receiving
Services
Program
Code
CSPP
Family Fee: Hourly $ 0
Sun.
School
Vacation
School
Vacation
School
Vacation
School
Vacation
Part-time Daily $
Enter Approved Hours of Enrollment
Tues.
Wed.
Thurs.
3
3
3
Fri.
3
6. Basis for Family Need for Services
(This section does not apply to State Preschool Programs [GPRE])
Recipient of Child Protective Services
Recipient of Child Protective Services
Current Aid Recipient
Child(ren) Identified as At Risk of Being Abused,
Neglected, or Exploited
Income Eligible (Reference Family Fee Schedule or
Income Ceiling for Admission to State Preschool
Programs.)
Child(ren) Identified as At Risk of Being Abused, Neglected, or
Exploited
Seeking Permanent Housing
Engaged in Vocational Training/Education
Employed or Seeking Employment
Incapacitated Parent(s)
7. Reason for Action: State the specific reason(s) services were denied, changed, or terminated.
8.
Agency Name
9.
Name/Title of Agency Representative
Sat.
Full-time $ 0
5. Basis for Family Eligibility for Services
Homeless
Mon.
3
Lakeside Union Elementary School District
10. Signature of Agency Representative
The agency must complete the information on the reverse side before the Notice of Action is issued.
NOTICE OF ACTION
CD-7617 (Rev.8/11) (REVERSE)
Appeal Information: If you do not agree with the agency’s action as stated in the Notice of Action, you may appeal the
intended action. To protect your appeal rights, you must follow the instructions described in each step listed below. If you
do not respond by the required due dates or fail to submit the required appeal information with your appeal request, your
appeal may be considered abandoned.
STEP 1: Complete the following appeal information to request a local hearing:
Name of Parent/Caretaker
Address
Telephone No.
City
Zip
In this section, please explain why you disagree with the agency’s action.
Check Box If an Interpreter is Needed at
the Local Hearing:
STEP 2:
Signature of Person Requesting a Local Hearing
Date
Mail or deliver your local hearing request within 14 days of receipt of this notice to:
This section must be completed by the agency before the notice is served
Lakeside Union Elementary School District
A. Agency Name
12824 Lakeshore Drive
B. Agency Address
Lakeside, Ca. 92040
C. City/State/Zip
D. Name of Agency Contact
E. Agency Telephone Number
STEP 3:
Within ten (10) calendar days following the agency’s receipt of your appeal request, the agency will notify you of the time
and place of the hearing. You or your authorized representative are required to attend the hearing. If you or your
representative do not attend the hearing, you abandon your rights to an appeal, and the action of the agency will be
implemented.
STEP 4:
Within ten (10) calendar days following the hearing, the agency shall mail or deliver to you a written decision.
STEP 5:
If you disagree with the written decision of the agency, you have 14 calendar days in which to appeal to the Early
Education and Support Division (EESD). Your appeal to the EESD must include the following documents and
information: (1) a written statement specifying the reasons you believe the agency’s decision was incorrect, (2) a
copy of the agency’s decision letter, and (3) a copy of both sides of this notice. You may either fax your appeal to
916-323-6853, or mail your appeal to the following address:
California Department of Education
Early Education and Support Division
1430 N Street, Suite 3410
Sacramento, CA 95814
Attn: Appeals Coordinator
Phone: 916-322-6233
STEP 6:
Within 30 calendar days after the receipt of your appeal, EESD will issue a written decision to you and the agency. If your
appeal is denied, the agency will stop providing child care and development services immediately upon receipt of CDE’s
decision letter.
Lakeside Union School District
EXTENDED STUDENT SERVICES
Lakeside Early Advantage Preschool
Lindo Park Elementary School, 12824 Lakeshore Dr, Lakeside, CA 92040
Preschool Director (619) 390-2391
Dear Parents and Guardians;
Please fill out this survey with any family needs. We can provide information of various agencies or groups to
try and meet your needs. If at this time you do not wish to request information, please check the box on the
bottom and sign and return to the Lakeside State Preschool office:
Please indicate below any services that you feel would be helpful to you or your family:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
ALCOHOL / DRUG ABUSE PREVENTION, EDUCATION, TREATMENT
ADULT / CHILD / SPOUSAL ABUSE PROGRAMS
CLOTHING REFERRALS
COUNSELING
DEVELOPMENTAL DELAY / DISABILITY SERVICES
EDUCATIONAL SERVICES
EMERGENCY ASSISTANCE
LAW ENFORCEMENT
LEGAL SERVICES
MEDICAL / DENTAL / MENTAL SERVICES
MILITARY SERVICES
PARENTING CLASSES
CHILD CARE
SENIOR SERVICES
PRENATAL CARE SERVICES
TANF – Temporary Assistance for Needy Family (FORMERLY YAFDC)
RECREATIONAL FACILITIES
NEIGHBORHOOD SECURITY / GANGS
LITERACY / REMEDIAL EDUCATION
Please list your most needed services:
1.
2.
3.
Please check here if services are not needed at this time.
PARENT SIGNATURE
CHILD’S NAME
DATE
CHILD’S TEACHER
2013-2014 School Year Lakeside Union School District
Application For Free and Reduced-Price Meals
(Complete
ONE Application per Household)
******USE BLACK OR BLUE INK AND PRINT NEATLY WITHIN BOXES******
SECTION A. CHILDREN INFORMATION
All Households Complete This Section. Enter all children, even if not attending school.
Place a circle around the correct Income Codes: W=Weekly, E=Every 2 Weeks, T=Twice a Month, M=Monthly, Y=Yearly.
Racial and Ethnic Identities (optional) 1. Circle one Ethnic Identity: N=Not Hispanic/Latino or H=Hispanic/Latino 2. Circle one or more racial identities: (Regardless of ethnicity)
A=Asian, W=White, B=Black or African American, I=American Native or Alsaka Native, P=Native Hawaiian or other Pacific Islander
SCHOOL
(Write "NONE" if not in
school)
GRADE
LAST NAME, FIRST NAME
Date of Birth
(Optional)
Racial and Ethnic Identities: (Optional)
Circle One
Circle one or more
Ethnic Identity

N
OR
H
A W B I P

N
OR
H
A W B I P

N
OR
H
A W B I P

N
OR
H
A W B I P

N
OR
H
A W B I P
If the child you are applying for is Homeless, Migrant, or Runaway, contact the
school and CIRCLE appropriate letter:
H M R
MARK "X"
Mark "X" if Child's Personal
If Foster
No Income Earned Income
Child





Source of
Income
(Work)?
Paid How Often?
(Circle)
$
W E T M Y
$
W E T M Y
$
W E T M Y
$
W E T M Y
$
ENTER Benefit Type: CalFresh,
CalWORKs,
Kin-GAP, FDPIR
ENTER Benefit Case
Number
W E T M Y
Households submitting an application with a Benefit Case Number for CalFresh/CalWORKs
for EACH child or an Adult household member, please skip to Section C and complete.
A Foster Child that is under the legal responsibility of a foster care agency or court, is eligible for
free meals. This eligiblity is not extended to non-foster children in the household.
Enter Gross Income Under Each Income Type each Household Member Receives and "How Often" the Income is Received by using the
SECTION B. ALL OTHER HOUSEHOLD MEMBERS:
following Income Codes: W=Weekly, E=Every 2 Weeks, T=Twice a Month, M=Monthly, Y=Yearly. If No Income, You MUST Mark the "No Income box." DO NOT Leave Blank.
Adult's Full Name
repeat names from Section A)
Richard, Larath
(Do not
MARK Gross Earnings from Work Paid Indicate Pay from Pensions,
Retirement, Social Security,
"X" If No
Before Deductions,
How
VA benefits
Often?
$
199.98
W
$
141.65
Income
Source?
Pension
Paid
How
Often?
Y
Welfare Benefits,
Child Support,
Alimony Payments
$
99.99
Income
Source?
Paid
How
Often?
Child Support
M
Any Other Income,
Including
Temporary Income
$

$
$
$
$
$
$
$


$
$
$
$

$
$
$
$

$
$
$
$
SECTION C. CONTACT INFORMATION, CERTIFICATIONS, AND SIGNATURE:
550.00
Income
Source?
Paid
How
Often?
Rental Income
M
Enter Benefit Type:
CalFresh, CalWORKS,
Kin-GAP, FDPIR
Enter Benefit
M
$
Education Code 49557(a): Applications for Free and reduced-price meals may be submitted at any
time during a school day. Children participating in the National School Lunch Program will not be overtly identified by the use of special tokens, special tickets, special serving lines, separate entrances, separate dining areas, or by
any other means. I certify (promise) that all of the above information is true and correct and that all income is reported. I understand that this information is given in given in connection with the receipt of federal funds that school
officials may verify the information on the application at any time, and that deliberate misrepresentation of the information may subject me to prosecution under applicable State and federal laws.
Signature of adult household member completing this form
Printed name of adult household member completing this form
Date
X ___________________________________________________ __________________
_______________________________________________________
Last 4 digits of Social Security Number (SSN)
___ ___ ___ ___
Federal Information Statement on
letter to households
 I do not have a SSN.
__________________________________________________________________________________________________________________________________________________________________________________________________________
Street Address, Apt #, etc.
City
State
Zip
Home Phone Number
Cell Phone Number
E-mail Address
DO NOT Write Below This Line-For School Use Only:
Application Approved:
 Free based on:
 CalFRESH
 CalWORKS
 KinGap
 FDPIR
 Direct Certification
HSLD Size: ________________
 Direct Certifed as:
H
 Household Income
 Zero Income
 Foster Child Only
M
R
HSLD Annual Income: $ ___________________
 Denied based on:
 Income Too High
 Incomplete
 Reduced based on:
 Household Income
Annual Income Conversion Factors: Weekly X 52, Every 2 Weeks X
26, Twice A Month X 24, Monthly X 12
The USDA and the CDE are equal opportunity providers and employers
Determining Official's Signature & Date
____________________________________________________ _______________
Confirming Official's Signature & Date
____________________________________________________ ________________
Verification Official's Signature & Date
____________________________________________________ ________________
Generated by the CA Dept. of Education mealapplicationJun2012