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257 Lawrence Street, Hartford CT 06106 |P (860) 721-7876| F (860) 257-1148 |

CCEH Children in Shelters Child Care Assistance Fund

APPLICATION FORM

Date: _______________________

Name of Parent(s): __________________________________________________________________________________

Agency Name ________________________________________________________________________________________

Agency is a: ______ Emergency Shelter ______ CT-Rapid Rehousing Program

⁭

Family Information:

Current Address: ______________________________________________________________________________

Phone__________________________________

Alternate Phone(work, cell, etc)____________________

Family Source(s) Of Income:

_____ Full-time job

_____ Part-time job _____ TANF

_____ Child Support

_____ SSI/SSD

_____Unemployment /Worker’s compensation

_____ Other (please specify) _______________

_____ No income

Total Monthly Income_______________________________

Children in need of childcare

Name____________________________________________________________ Date of Birth_____________________

Child(ren) with special needs? _____ Yes

_____ No

Please indicate which child and their special need:

________________________________________________________________________________________________________

Care 4 Kids application: required if parent is working. Shelter/CT-RRP is required to

maintain a copy of applicant Care 4 Kids application in client file. If parent is not working,

indicate Not Applicable.

Care 4 Kids Application submission date__________________ Approval Date ___________________

Childcare Provider Information:

Name of Child Care Provider________________________________________________________________________

Address: _____________________________________________________________________________________________

Mailing Address for Payment, if different from above:

________________________________________________________________________________________________________

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Cceh Children In Shelters Child Care Assistance Fund Application Form - Connecticut Coalition To End Homelessness