Waitlist Application for Childcare Financial Assistance

Please fill out the waitlist application to the best of your ability. This form will be used to determine if you are eligible for placement on the waiting list for childcare financial assistance.

Primary Parent - Last Name: ***First Name: ***M.I.D.O.B (mm/dd/yy)
Spouse - Last Name: First Name: M.I.D.O.B (mm/dd/yy)
Residence Address: ***City: ***State: **Zip: ***
Mailing Address: (if different)City:State:Zip:
Home Phone:Cell Phone:Fax:
Email Address: ***
Family Size: ***  
Parent 1 Employer Name: Phone:
    Hourly Pay Rate: $     Hours worked per week:
Parent 2 Employer Name: Phone:
    Hourly Pay Rate: $     Hours worked per week:
School Name: Phone:
Child(ren) in Household
    Check the 'W/L' box to the left of each child if you want them on waiting list.

W/L  Last Name***First Name***DOB***Race***Gender***
   MF
   MF
   MF
   MF
   MF
   MF
Household Income Sources
    List all income that are applicable in dollar amounts received.

Income Source   Parent 1How Often?Parent 2How Often?
Child Support
SSI
Soc. Sec. Survivors Ben
TANF
Other(Specify)

   I hereby consent to have the information contained in this document verified for possible placement on the waiting list for childcare financial assistance. I certify that all the information is complete and true to the best of my knowledge.

  Submit Waitlist Application