Procare

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UCSC Early Education Services

599 Koshland Way , Santa Cruz, CA, 95064, United States

1

Student info

2

Parent info

3

Authorized Pickup Info

4

Policy & Waiver

5

Review

Student #1

Child First Name

Child Last Name

Date of Birth

Select Date

Has your child previously been in group care? Is there anything you'd like to share about your child?

Gender

Preferred Start Date

Select Date

Program Request

Program Request

UCSC Family Affiliation

UCSC Affliation

Family Household Size

Family Household Income

Total Income of the Household

Childcare Need

Childcare Need

Childcare Need - Other Explanation

Family Street Address

City

State

Current/Future Housing

Current/Future Housing

Young Infant (3mo - 12mo)

Older Infants (12mo - 24mo)

Two's (24mo - 36mo)

Preschool (3 - 4 year olds)

School-Age (After-School Program)

Undergraduate UCSC Student

Graduate UCSC Student

Staff

Faculty

Community (Not affiliated with UCSC)

2 (Single Parent with one child)

3

4

5

More than 6

$0 - $25,000/year

$25,001 - 50,000/year)

$50,001 - 75,000/year

$75,001 - $84,000/year

$84,001 - $97,000/year

$97,001 - 110,000/year

$110,001 - 125,000/year

$125,001 - 132,000/year

Above $132,000/year

Single Family Household - Parent is a full-time Student

Single Family Household - Parent is employed full time

Dual Family Household - Both parents are full-time students

Dual Family Household - Both parents are full-time employed

Dual Family Household - One parent is a full-time student, one parent is employed full-time

Dual Family Household - One parent is a student or employed, one parent is not a student/employed

Dual Family Household - Other (please explain below)

We currently/plan to live at UCSC Family Student Housing

We currently/plan to live off-campus near UCSC

Other