Child Care Application And Authorization Form
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Certified Domestic Violence Center or Designated Homeless Program
THIS FORM IS VOID AFTER 10 CALENDAR DAYS FROM AUTHORIZATION DATE
Authorization
☐
INITIAL AUTHORIZATION
Type:
☐
REDETERMINATION
FROM: (Print Worker Name)
Phone Number
Organization Name
Mailing Address, City, Zip Code
SECTION A: FAMILY INFORMATION
Parent/Guardian #1 Social Security No.
(Print) Last Name
First Name
MI
Date of Birth
Gender
Race
(optional)
Marital Status:
☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Separated
Parent/Guardian #2 Social Security No.
(Print) Last Name
First Name
MI
Date of Birth
Gender
Race
(optional)
Marital Status:
☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Separated
Mailing Address:
City
State
Zip Code
Contact Phone No.
CHILD INFORMATION
Child Social Security No. (optional)
(Print) Last Name
First Name
MI
Date of Birth
Gender
Race
Child Social Security No. (optional)
(Print) Last Name
First Name
MI
Date of Birth
Gender
Race
Child Social Security No. (optional)
(Print) Last Name
First Name
MI
Date of Birth
Gender
Race
Note: Use the CLARIFYING COMMENTS section if there are more than three children for one referral.
SECTION B: ELIGIBILITY
At-Risk Status:
☐ Designated Homeless Program Participant
☐ Certified Domestic Violence Center Resident
Please select one of the reasons for purpose of care:
Comments:
Verification of the Following (with Documentation
☐
U.S. Citizen or Qualified Alien
Attached):
☐
Verification of Age
For child(ren) needing care:
SECTION C: AUTHORIZATION
Hours: Child care service is authorized for this client for approved activity(ies) not to exceed a total of ______ hours per week.
This total includes ______ hours per week for reasonable transportation time.
Dates: Child Care Authorization From ______/______/______ through ______/______/______.
(3 months or less for domestic violence center resident and 6 months or less for homeless program participant)
SECTION D: AUTHORIZING SIGNATURES
I hereby certify that the information provided above is correct.
Applicant Signature:
Date: ____________________
Worker Authorizing Referral Signature:
Date: ____________________
Coalition Staff: (Print) ________________________________ Signature:_____________________________
Date:_____________________
Child Care Application and Authorization Form
Form OEL-DV/HM 01, Part A (July 2013)
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