Child Care Application Page 6
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19State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE APPLICATION
Parent/Guardian Name:
WORK INFORMATION -
If they are working more than one job, they MUST tell us about all their jobs even if they
Number of jobs currently working
don't need child care for that job. Photocopy this page and complete a separate work information and work schedule
section for each job they have.
Job Title
First Employer/Company Name
Address
City
State
Zip Code
Work Telephone Number
Ext.
Date you started this job:
$
$
$
They earn before deductions (complete one):
per hour OR
per month OR
per year
They get paid (check one):
Number of hours usually worked at
Number of days usually worked at this
every day
every week
this job each week
job each week
every two weeks
twice per month
once per month
other (please explain)
Do they use public transportation?
Travel time from the child care provider to work:
Yes
No
WORK SCHEDULE: If their schedule varies, provide an example of their schedule.
MON
TUES
WED
THURS
FRI
SAT
SUN
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
TO
PM
PM
PM
PM
PM
PM
PM
If their schedule varies, please explain how (they may send additional documentation to verify, see Frequently Asked Questions #11 on page 16 of this application):
Second Employer/Company Name
Job Title
Address
City
State
Zip Code
Work Telephone Number
Ext.
Date they started this job:
$
$
$
per hour OR
per month OR
per year
They earn before deductions (complete one):
They get paid (check one):
Number of hours usually worked at
Number of days usually worked at this
every day
every week
this job each week
job each week
every two weeks
twice per month
once per month
other (please explain)
Do they use public transportation?
Travel time from the child care provider to work:
Yes
No
WORK SCHEDULE: If their schedule varies, provide an example of their schedule.
MON
TUES
WED
THURS
FRI
SAT
SUN
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
AM
AM
AM
AM
AM
AM
AM
TO
PM
PM
PM
PM
PM
PM
PM
If their schedule varies, please explain how (they may send additional documentation to verify, see Frequently Asked Questions #11 on page 16 of this application):
IL444-3455 (R-6-11)
Page 5 of 17
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