Child Care Application (Page 5 of 19) in pdf

State of Illinois

Department of Human Services - Bureau of Child Care and Development

CHILD CARE APPLICATION

Parent/Guardian Name:

Are you currently attending school, training or a TANF-Required Activity?

No (Go to Section 2 - Other Parent/Stepparent Information)

Yes (Complete the information below.)

SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION

Type of Degree Being Earned

TYPE OF EDUCATION/TRAINING CURRENTLY ATTENDING: (Check one)

High School or GED

Below Post - Secondary (e.g., ABE or ESL)

Internship

Occupational/Vocational

2-Year College Degree

4-Year College Degree

Work Experience (TANF only)

Do you already have a professional license degree, or certificate?

What is the highest level of education you have completed (GED/High school

Yes

diploma, trade school certificate, BA degree)?

If yes, what type:

School Name/Training Program Currently Attending

Telephone Number

Term Start Date

Term End Date

City

Address

State

Zip Code

Do you use public transportation?

Yes

Travel time from the child care provider to school.

SCHOOL SCHEDULE: Please complete the following schedule

MON

TUES

WED

THURS

FRI

SAT

SUN

FROM

SECTION 2 - OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION

Is the other parent or stepparent of any of your children, step children or wards living in your home?

No (Go to Section 3 - Family Information p. 6)

Yes (Complete the information below.)

Please note: Information from various agencies' databases and internet web sites will be taken into consideration (See

Question #6 on page 15). If the information does not match it may delay your eligibility.

If the other parent or step parent could be listed on your case for other benefits TANF, SNAP/Food Stamps, Medical, Child

Support Enforcement, Unemployment), but is no longer living with you, you may need to supply additional information to prove

he/she is living somewhere else. If you cannot provide this documentation, please contact your local CCR&R or Site

Administered child care provider.

OTHER PARENT/GUARDIAN/STEPPARENT INFORMATION

Last Name

Other Parent/Guardian/Stepparent First Name

M.I.

Social Security Number (Optional)

Telephone Number

Date of Birth (include month/day/year)

Is the other parent or stepparent working?

Yes

Is the other parent or stepparent attending school or a training program?

Yes

If the ot

her parent or stepparent is not working or in a school/training program, please explain why they cannot care for the children.

IL444-3455 (R-6-11)

Page 4 of 17

Child Care Application Page 5

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