Subsidized Child Care Application Form - Commonwealth Of Pennsylvania Page 2

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The Child Care Information Services (CCIS) agency offers parents resource and referral services to connect them with child care arrangements in their communities. The CCIS also provides

information to parents about whether they are eligible for help in paying their child care costs. To locate a CCIS near you, call 1-877-PA-KIDS (1-877-472-5437), or to contact your local CCIS agency:

CHILD CARE INFORMATION SERVICES AGENCY:

Directions for Completing the Application for Subsidized Child Care

The information you provide on this application is confidential.

1. Fill out the form. Please print. You must return pages 2-8 to the CCIS agency. Two-parent/caretaker families must return pages 2-10 to the CCIS agency (i.e.,

pages 7-8 are to be completed for the primary parent/caretaker and pages 9-10 are to be completed for the primary parent’s/caretaker’s spouse.) You must also

sign and date this application.

2. Mail, fax or take this application to your local CCIS agency. Call 1-877-PA-KIDS (1-877-472-5437) if you do not know where to send this application or you need

help with this application. If you are hearing impaired, you can use your TTY service to call 1-877-PA-KIDS (1-877-472-5437).

3. You may complete and submit an application online at:

VERY IMPORTANT:

Two-parent families: Both parents must be working; however, if the second parent is not working because of a disability and is unable to care for the children, he/

she must have a doctor complete a Medical Assessment form. If you need a copy of this form, call the CCIS.

Foster parents: If you are applying for a foster child, attach a letter from the county children and youth agency that approves the foster child to be in care.

Please list the people who live with you.

NOTE: Please list your biological or adoptive children and any other child(ren) for whom you are responsible.

Last Name

First Name

M.I.

Date of

Sex

Social

How is this

Marital

Does this child

On what day does this child need child care?