Name *

First Name

Last Name

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Currently Homeless *

Select an option

Yes

No

Contact Phone Number *

(###)

###

####

For most subsidies, each parent must state their need for childcare from the options below. *

Check all that apply

Working – Parent/Guardian is currently employed/self employed

Incapacity/On Disability – Parent/Guardian is currently incapacitated/on Disability

Seeking Employment – Parent /Guardian is currently seeking employment

Attending School or Vocational Training – Parent/Guardian is attending school/vocational training

Homeless or Seeking Permanent Housing – Family is currently homeless/seeking permanent housing

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone Number

(###)

###

####

For most subsidies, each parent must state their need for childcare from the options below.

Check all that apply

Working – Parent/Guardian is currently employed/self employed

Incapacity/On Disability – Parent/Guardian is currently incapacitated/on Disability

Seeking Employment – Parent /Guardian is currently seeking employment

Attending School or Vocational Training – Parent/Guardian is attending school/vocational training

Homeless or Seeking Permanent Housing – Family is currently homeless/seeking permanent housing

Name *

If you are applying before the birth of your child and do not know your child’s name yet, please write as: “Last Name, Baby.” Also, please follow up when your child is born with the exact birth date, gender and name.

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Race *

Select all that apply

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

Caucasian

Hispanic or Latino

Is this child involved in an active Child Protective Services or at risk of being involved in a Child Protective Services case?

This information is optional, but families with a verified history of receiving services may be prioritized for financial assistance.

CPS - Check this box if your family is actively working with a Child Protective Social Worker for this child.Check this box if your family is actively working with a Child Protective Social Worker for this child.

At Risk - Check this box if your family has a letter from a legally qualified professional (licensed social worker, therapist, teacher, lawyer, etc.) stating this child is 'at risk of neglect, abuse or exploitation.' You will be able to upload the letter later in this application.

Contact Phone Number

(###)

###

####

Date *

MM

DD

YYYY