New Client Enrollment Form

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- Step 1 of 9

First Parent Information

Parent Name *

First

Last

Parent's Social Security Number *

Marital Status *

Married
Single

Family Size *

Contact Information

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Other Information

Ethnicity

Cash Aid

My last date of Aid

Second Parent Information

Is Second Parent living at home? *

2nd Parent Name *

First

Last

2nd Parent's Social Security Number *

Contact Information

2nd Parent Email *

2nd Parent Phone *

Is your income over the 85 percentile? *

Children Information

Number of Children *

1st Child Information

Child Name *

First

Last

Date of Birth *

Do you need child care for this child? *

1st Date of Care Needed *

Is your 1st child enrolled in another subsidized program or Head Start? *

Current Hours of Care Received at Another Subsidized Care Program or Head Start

*If applicable

Monday In

Monday Out

Tuesday In

Tuesday Out

Wednesday In

Wednesday Out

Thursday In

Thursday Out

Friday In

Friday Out

1st Child's Child Care Provider Name *

First

Last

1st Child Provider's Address *

Address Line 1

Address Line 2

City

State

Zip Code

1st Child Provider Phone # *

1st Child Provider Email Address *

Are you using a licensed child care center or licensed family day care home? *

Has your provider cleared TrustLine/fingerprint clearance?

Child Care will be provided in *

2nd Child Information

Child Name *

First

Last

Date of Birth *

Do you need child care for your 2nd child? *

1st Date of Care Needed *

Is your 2nd child enrolled in another subsidized program or Head Start? *

Current Hours of Care Received at Another Subsidized Care Program or Head Start

*If applicable

Monday In

Monday Out

Tuesday In

Tuesday Out

Wednesday In

Wednesday Out

Thursday In

Thursday Out

Friday In

Friday Out

2nd Child's Child Care Provider Name *

First

Last

2nd Child Provider's Address *

Address Line 1

Address Line 2

City

State

Zip Code

2nd Child Provider Phone # *

2nd Child Provider Email Address *

Are you using a licensed child care center or licensed family day care home? *

Has your provider cleared TrustLine/fingerprint clearance?

Child Care will be provided in *

3rd Child Information

Child Name *

First

Last

Date of Birth *

Do you need child care for your 3rd child? *

1st Date of Care Needed *

Is your 3rd child enrolled in another subsidized program or Head Start? *

Current Hours of Care Received at Another Subsidized Care Program or Head Start

*If applicable

Monday In

Monday Out

Tuesday In

Tuesday Out

Wednesday In

Wednesday Out

Thursday In

Thursday Out

Friday In

Friday Out

3rd Child's Child Care Provider Name *

First

Last

3rd Child Provider's Address *

Address Line 1

Address Line 2

City

State

Zip Code

3rd Child Provider Phone # *

3rd Child Provider Email Address *

Are you using a licensed child care center or licensed family day care home? *

Has your provider cleared TrustLine/fingerprint clearance?

Child Care will be provided in: *

Child Name *

First

Last

Date of Birth *

Do you need child care for your 4th child? *

1st Date of Care Needed *

Is your 4th child enrolled in another subsidized program or Head Start? *

Current Hours of Care Received at Another Subsidized Care Program or Head Start

*If applicable

Monday In

Monday Out

Tuesday In

Tuesday Out

Wednesday In

Wednesday Out

Thursday In

Thursday Out

Friday In

Friday Out

4th Child's Child Care Provider Name *

First

Last

4th Child Provider's Address *

Address Line 1

Address Line 2

City

State

Zip Code

4th Child Provider Phone # *

4th Child Provider Email Address

4th Child Provider Email Address *

Are you using a licensed child care center or licensed family day care home? *

Has your provider cleared TrustLine/fingerprint clearance?

Child Care will be provided in: *

Verification

Upload File

Drag & Drop Files, Choose Files to Upload

Upload any supporting documents

Digital Signature *

Clear Signature

Sign Above

Signature Date *

Please confirm that your income is over the 85th percentile. *

Additional Information

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