Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 6

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State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE APPLICATION
Parent/Guardian Name:
OTHER PARENT'S SCHOOL/TRAINING/TANF-REQUIRED ACTIVITY INFORMATION
Do they already have a professional license degree , or certificate?
What is the highest level of education they 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
Address
City
State
Zip Code
Do they use public transportation?
Yes
Travel time from the child care provider to school:
No
Is the other parent/guardian/stepparent currently attending school, training or a TANF - Required Activity?
No (Go to Section 3 - Family Information - below).
Yes (Complete the information below.)
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)
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 3 - FAMILY INFORMATION
Family size includes these people LIVING IN YOUR HOME:
*
You,
*
Your biological or adopted children under age 21.
*
The biological, step or adoptive parent of any of your children must be included.
*
Any other person related to you by blood or law for whom you provide more than 50% of their support (if you choose to
include them and can verify their income) - for example an elderly parent or disabled person.
My family size:
IL444-3455 (R-6-11)
Page 6 of 17

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