Please enable JavaScript in your browser to complete this form. - Step 1 of 9First Parent InformationParent Name *FirstLastParent's Social Security Number *Marital Status *MarriedSingleFamily Size *Contact InformationAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Phone *Other InformationEthnicityAfrican AmericanAmerican IndianAsianHispanic-LatinoNative Hawaiian-Pacific IslanderCaucasianDecline to StateCash AidI am currently receiving cash aid for myself and my childrenI received cash aid within the past two year for myself and my childrenMy last date of AidNextSecond Parent InformationIs Second Parent living at home? *YesNo2nd Parent Name *FirstLast2nd Parent's Social Security Number *Contact Information2nd Parent Email *2nd Parent Phone *PreviousNextIs your income over the 85 percentile? *YesNoPreviousNextChildren InformationNumber of Children *1234PreviousNext1st Child InformationChild Name *FirstLastDate of Birth *Do you need child care for this child? *NoYes1st Date of Care Needed *Is your 1st child enrolled in another subsidized program or Head Start? *NoYesCurrent Hours of Care Received at Another Subsidized Care Program or Head Start*If applicableMonday InMonday OutTuesday InTuesday OutWednesday InWednesday OutThursday InThursday OutFriday InFriday Out1st Child's Child Care Provider Name *FirstLast1st Child Provider's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code1st Child Provider Phone # *1st Child Provider Email Address *Are you using a licensed child care center or licensed family day care home? *YesNoHas your provider cleared TrustLine/fingerprint clearance?YesNoChild Care will be provided in *Provider's HomeChild's HomeChild Care CenterPreviousNext2nd Child InformationChild Name *FirstLastDate of Birth *Do you need child care for your 2nd child? *NoYes1st Date of Care Needed *Is your 2nd child enrolled in another subsidized program or Head Start? *NoYesCurrent Hours of Care Received at Another Subsidized Care Program or Head Start*If applicableMonday InMonday OutTuesday InTuesday OutWednesday InWednesday OutThursday InThursday OutFriday InFriday Out 2nd Child's Child Care Provider Name *FirstLast2nd Child Provider's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code2nd Child Provider Phone # *2nd Child Provider Email Address *Are you using a licensed child care center or licensed family day care home? *YesNoHas your provider cleared TrustLine/fingerprint clearance?YesNoChild Care will be provided in *Provider's HomeChild's HomeChild Care CenterPreviousNext3rd Child Information Child Name *FirstLastDate of Birth *Do you need child care for your 3rd child? *NoYes1st Date of Care Needed *Is your 3rd child enrolled in another subsidized program or Head Start? *NoYesCurrent Hours of Care Received at Another Subsidized Care Program or Head Start*If applicableMonday InMonday OutTuesday InTuesday OutWednesday InWednesday OutThursday In Thursday OutFriday InFriday Out3rd Child's Child Care Provider Name *FirstLast3rd Child Provider's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code3rd Child Provider Phone # *3rd Child Provider Email Address *Are you using a licensed child care center or licensed family day care home? *YesNoHas your provider cleared TrustLine/fingerprint clearance? YesNoChild Care will be provided in: *Provider's HomeChild's HomeChild Care CenterPreviousNextChild Name *FirstLastDate of Birth *Do you need child care for your 4th child? *NoYes1st Date of Care Needed *Is your 4th child enrolled in another subsidized program or Head Start? *NoYesCurrent Hours of Care Received at Another Subsidized Care Program or Head Start*If applicableMonday InMonday OutTuesday InTuesday OutWednesday InWednesday OutThursday InThursday OutFriday InFriday Out4th Child's Child Care Provider Name *FirstLast4th Child Provider's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code4th Child Provider Phone # *4th Child Provider Email Address4th Child Provider Email Address *Are you using a licensed child care center or licensed family day care home? *YesNoHas your provider cleared TrustLine/fingerprint clearance? YesNoChild Care will be provided in: *Provider's HomeChild's HomeChild Care CenterPreviousNextVerificationUpload File Click or drag a file to this area to upload. Upload any supporting documentsDigital Signature * Clear Signature Sign AboveSignature Date *Please confirm that your income is over the 85th percentile. *YesPreviousSubmit Additional Information Photo by Element5 Digital on Unsplash
