PRELIMINARY APPLICATION 
Summer Only  
 
 
 
 
 
 
 
                           No.: ____ 
 
PARENT’S NAME:  _________________________________________ FAMILY SIZE: _______ 
 
SS#________________________(required)_________________Single_______________Married 
 
MAILING ADDRESS: ___________________________________________________________ 
 
 
 
            ___________________________________________________________ 
 
 
    
TELEPHONE NOS.: ____________________         _________________   ________________ 
                                              WORK                                         CELL                             HOME 
 
EMAIL ADDRESS: _____________________________________________________________ 
 
PLACE OF EMPLOYMENT: _______________________________Phone#________________ 
 
 
ARE YOU A TEEN PARENT?             YES          NO 
 
ANNUAL INCOME: $_________________________    
 
NAME OF CHILD (REN) 
_________________________   DOB: ________________ 
 
 
 
 
 
_________________________   DOB: ________________ 
 
 
 
 
 
_________________________   DOB: ________________ 
 
_________________________   DOB: ________________ 
 
 
 
 
 
 
Have you applied for or are you receiving childcare services from any of the following?  
[ ] Head Start    [ ] Early Head Start    [ ] AmeriCorps    [ ] Labor    [ ] Military    [ ] Other  
 
 
 
______________________ 
 
 
 
 
__________________ 
    Signature of Applicant 
 
 
 
 
 
 Date 
 
OFFICIAL USE ONLY 
 
[ ] ELIGIBILITY      [ ] COMPLETED      [ ] NO LONGER      [ ] NO SHOW      [ ] OTHER   
 
[ ] INELIGIBILITY   [ ] IN SUFFICIENT HOURS   [ ] NOT IN A COMPONENT   [ ] OVERQUALIFIED 
 
 
 
 If you are found eligible, you will be placed on the waiting list upon the availability of funds; 
however, if you are ineligible, you will be notified.  
Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930  
3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980, (340)772-7147