Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 4
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17State 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
No
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?
Travel time from the child care provider to school.
Yes
No
SCHOOL SCHEDULE: Please complete the following 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
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)
Date of Birth (include month/day/year)
Telephone Number
Is the other parent or stepparent working?
Yes
No
Is the other parent or stepparent attending school or a training program?
Yes
No
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
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