Subsidized Child Care Application Form - Commonwealth Of Pennsylvania Page 4

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Language Preference

What language do you speak primarily?

What language do you read primarily?

Prior Benefits

Have you or your spouse received TANF cash assistance within the past 183 days? £ Yes £ No If yes, where? £ Pennsylvania £ Other State

Do you currently receive Food Stamps? £ Yes £ No

Do you currently receive housing assistance? £ Yes £ No

Immunization Certificate

I certify that my child(ren):

Child(ren) who has/have age-appropriate immunizations

£ has/have the recommended, age-appropriate immunizations

I certify that my child(ren):

Child(ren) who has/have NOT received age-appropriate immunizations

£ does/do not have the recommended, age-appropriate immunizations because of:

£ Religious beliefs

£ A medical condition of the child

Signature of Parent/Caretaker

Date

Education

Are you currently enrolled in an elementary, middle, junior high or senior high school or a GED program?

£ Yes £ No

If yes, do you need child care while you attend your educational program?

£ Yes £ No

If you answered yes to BOTH questions, or are under 18 years of age, you MUST attach proof of the hours and days you attend school. Proof includes a copy of your

school schedule, a letter from your school that states the hours and days you attend school or an Education Verification form. If you need a copy of the Education

Verification form, call the CCIS.

Training

Do you currently attend a training program?

£ Yes £ No

If yes, do you need child care while you attend your training program?

£ Yes £ No

If you answered yes to BOTH questions above, you MUST attach proof of the hours and days you attend training. Proof includes a copy of your training schedule, a let-

ter from your training representative that states the hours and days you attend training or a Training Verification form. If you need a copy of the Training Verification

form, call the CCIS.

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