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2. Date:
   Date:

   Date:
4. Name:
6. Mailing address:
8. City
9. State
10. Zip
12. Phone number:
13. Alternate phone number:
15. Are you?

    1. Single
    2. Married
    3. Separated
    4. Divorced
17. Please list the names, dates of birth and Social Security Numbers of each adult in the household, including yourself.
19. Name:
20. Date of birth:
    Date of birth:
21. Social Security number:
23. Name:
24. Date of birth:
    Date of birth:
25. Social Security number:
27. Are you employed for at least 25 hours per week?

    1. Yes
    2. No
29. Where are you employed?
    Please name the place of employment for each adult, including yourself.
31. Please list the hourly rate, hours per week, and how often paid for each adult, including yourself
33. Name:
34. Hourly rate:
35. Hours per week:
36. Pay schedule:
    Monthly / Weekly, etc.
38. Please enter the monthly amount of any other assistance or income currently being received.
40. TANF:
41. SNAP / Food Stamps:
42. SSI:
43. Child support:
45. Are you enrolled in school or training?

    1. Yes
    2. No
46. What is your school / training schedule?

    1. Full-time
    2. Part-time
48. Do you have a cumulative grade point average (GPA) of 2.0 or above?

    1. Yes
    2. No

    You will have to provide verification of your GPA upon review of eligibility for possible enrollment.
50. Where do you go to school? Please name the school attended for each adult, including yourself:
52. Are you a veteran?

    1. Yes
    2. No
54. Please list the names, date(s) of birth, and Social Security number(s) for the child(ren) who need childcare.
56. Name:
57. Date of birth:
58. Social Security number:
60. Name:
61. Date of birth:
62. Social Security number:
64. Name:
65. Date of birth:
66. Social Security number:
68. Name:
69. Date of birth:
70. Social Security number:
72. List any other children who do not need childcare and give their date(s) of birth and Social Security number(s).
74. Name:
75. Date of birth:
76. Social Security number:
78. Name:
79. Date of birth:
80. Social Security number:
82. Name:
83. Date of birth:
84. Social Security number:
86. Name:
87. Date of birth:
88. Social Security number:
90. Have you received childcare through Child Care Services before?

    1. Yes
    2. No
92. When?
    When? Start Date

    —

    When? End Date
93. Where?
95. Please enter the name of the school and schedule your child attends if attending public elementary, Head Start, or other such programs.
97. It is not mandatory that you answer the following questions, however it would be helpful in providing services to your family.
99. Has your child received Early Childhood Intervention services (ECI)?

    1. Yes
    2. No
101. Does your child have a special education or resource teacher?

     1. Yes
     2. No
103. Does the child(ren) have any disabilities or special needs?

     1. Yes
     2. No
105. Do you have any other family needs?

     1. Yes
     2. No
107. Are you interested in receiving family enrichment services?

     1. Yes
     2. No
109. Can we give your name and number to a Family Enrichment Service?

     1. Yes
     2. No
111. Please be sure to contact us every 60 days or less to update your child(ren) on the wait list in order to avoid being taken off of the wait-list.
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112. Print Only

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