Application Solicitud en Español Child’s Information Child’s First Name* Child’s Last Name* Child’s Birth Date* Child must be born on or before August 27, 2018 to be eligible for the 2020-21 school year. We are presently accepting applications for the 2020-21 school year. The deadline for 2020-21 applications is February 14, 2020. If you would like to be considered for the 2019-2020 school year waiting pool, please email firstname.lastname@example.org after submitting your application. Child’s Gender* –None–FemaleMalePrefer to self describe Prefer to self describe Gender Ethnicity – Child* Hispanic or LatinoAmerican Indian or Alaska NativeAsianBlack or African AmericanPacific IslanderWhiteMulti Ethnic / Other Primary Language – Child* Secondary Langauge – Child Street Address City State/Province Zip Country Parent/Guardian 1 First Name – Parent 1* Last Name – Parent 1* Ethnicity – Parent 1* Hispanic or LatinoAmerican Indian or Alaska NativeAsianBlack or African AmericanPacific IslanderWhiteMulti Ethnic / Other Primary Language – Parent 1* Secondary Language – Parent 1 Occupation Special Skills/Expertise Phone Number* Email Parent/Guardian 2 First Name – Parent 2 Last Name – Parent 2 Ethnicity – Parent 2 Hispanic or LatinoAmerican Indian or Alaska NativeAsianBlack or African AmericanPacific IslanderWhiteMulti Ethnic / Other Primary Language – Parent 2 Secondary Language – Parent 2 Occupation Special Skills/Expertise Phone Number Email Availability How many days per week would you like your child to attend?* –None–12345 Preferred Days (please use Ctrl, Alt or Command key to select multiple days)* MondayTuesdayWednesdayThursdayFriday Please list family members who would serve as Parent Teachers* Are you interested in the option to buy out of shift requirements? Are you interested in working extra shifts in exchange for dues reduction? If you are low income, would your family be interested in applying for a scholarship? Volunteer Interests (please use Ctrl, Alt or Command key to select multiple interests)* Administration/EventsCurriculumFacility MaintenanceField TripsFund-raisingOtherWebsite/content Preferred Shifts (please use Ctrl, Alt or Command key to select multiple shifts)* M-amM-pmT-amT-pmW-amW-pmTh-amTh-pmF-amF-pm Child/Family Info Names and ages of siblings. Why would your child and family be a good fit for the co-op? Please describe how your family can contribute to our school’s diversity. Summarize your child’s previous experiences with preschool or childcare. How did you hear about Mission Kids? Family Income Limits Family of: 1 person 2 people 3 people 4 people 5 people 6 people 7 people 8 people Extremely Low Income $33,850 $38,700 $43,350 $48,350 $52,250 $56,100 $60,000 $63,850 Low Income $64,116 $64,116 $69,624 $80,628 $93,528 $106,428 $108,840 $111,264 Moderate Income $108,348 $108,348 $121,956 $135,456 $146,304 $157,152 $167,952 $178,800 Above Moderate Income 1 $175,000 $175,000 $175,000 $175,000 $175,000 $175,000 $175,000 $180,000 Above Moderate Income 2 $250,000 $250,000 $250,000 $250,000 $250,000 $250,000 $250,000 $250,000 Above Moderate Income 3 >$250,000 >$250,000 >$250,000 >$250,000 >$250,000 >$250,000 >$250,000 >$250,000 Please reference the grid to indicate your family income level* –None–Extremely Low IncomeLow IncomeModerate IncomeAbove Moderate IncomeAMI 1AMI 2AMI 3 Additional comments or clarifications: By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if my child is accepted at Mission Kids Co-op, any false statements, omissions, or other misrepresentations made by me on this application may result in our family’s immediate dismissal.* **You must confirm the reCAPTCHA selection in the box above for this button to enable** After submitting this application, you should receive a confirmation email within 2 days. If you do not, please contact us at email@example.com. Thank you!