Name Of Preschool:
FallWinterSpring
Two (2) DaysThree (3) DaysFour (4) Days

Background Information (Confidential)

Child's Name
Date Of Birth
Child's Age

Names of parents or other adults in home:
Last Name
First Name
Middle Initial
Phone Number
Work Number
Address

Last Name
First Name
Middle Initial
Phone Number
Work Number
Address

Last Name
First Name
Middle Initial
Phone Number
Work Number
Address

Names and birth dates of minor children in home:

Last Name
First Name
Middle Initial
Date Of Birth
Child's Age

Last Name
First Name
Middle Initial
Date Of Birth
Child's Age

Last Name
First Name
Middle Initial
Date Of Birth
Child's Age

Total number of members in household

Financial Information (Confidential)

YOU MUST SUBMIT PREVIOUS YEAR COPIES OF W2S AND CURRENT AND LAST 30 DAYS OF EACH WAGE EARNER(S) EMPLOYER PAY SLIPS

Sources Of Income (Monthly)
Adult Name
Employer Name
Monthly Income
Employer Address
Employer City
Employer Zip
Employer Phone
Length Of Time Employed
PermanentSeasonal

Adult Name
Employer Name
Monthly Income
Employer Address
Employer City
Employer Zip
Employer Phone
Length Of Time Employed
PermanentSeasonal

Other Sources Of Income:

DSHS
Social Security/Disability
Child Support
Alimony

Do you receive other funding help for preschool or child?
YesNo
If yes, what is the monthly amount?

Do you receive income from any other source?
YesNo
If yes, what is the monthly amount?

Total Monthly Net Income

Parental, Housing And Medical Information

Parental Status
Financial Information - check all that apply:
Two Parent HouseholdSingle ParentSingle Parent Enrolled In SchoolFoster ParentsEnglish as a Second LanguageOther Adults In Home

Housing Status Satisfactory HousingTemporary HousingHomeless

Special medical needs of child (please list):

Please provide information on special circumstances not addressed in the previous sections.

If scans of your pay stubs are available, please upload them here.

If scans of your tax returns are available, please upload them here.

Applicant Information Certification

By submitting this form, I certify that all of the provided background and income information is true and correct and that all income is reported. All content is confidential and is only used for the purpose of granting preschool scholarship.

Applicant Name
Applicant Email
Applicant Phone Number

I would like to become involved with the Family Umbrella Group as a:
Board MemberVolunteer