Child Care Application

You may be eligible to receive child care while searching for work that will meet minimum employment activity.

If you meet the requirements and would like to apply for child care assistance please complete the following application. Your submission will be sent to our team.


To speak to a child care specialist please call 1-800-996-7589 or 325-653-2321.

Submitting this application does not guarantee eligibility. Applicants should expect contact through email or phone call from a CCS representative that will inform them of if they qualify for CCS and whether they will be placed on the wait list

Initial Evaluation of Eligibility

  1. All fields must be filled. For fields that do not apply to you, please type "N/A" or "Does not apply".
  2. Mailing Address
  3. Physical Address
  4. Check all that apply to your household:*
  5. Are you:*
  6. List the requested personal information of each adult in the household including yourself:
  7. Are you currently unemployed and looking for work?*
  8. Are you employed for 25 or more hours per week?*
  9. Are you employed for less than 25 hours per week?*
  10. List the place of employment for each adult including yourself:
  11. List the requested employment information for each adult including yourself:
  12. Do you receive regular bonuses?*
  13. Enter the monthly amount of any other assistance or income currently being received:
  14. Are you currently enrolled in school/training?*
  15. You will have to provide verification of current enrollment upon request.

  16. List the child(ren) who NEED childcare:
  17. List the child(ren) who DO NOT NEED childcare:
  18. Is your child currently enrolled at a childcare provider?*
  19. Have you received childcare through Child Care Services before?*
  20. Please list 2 contacts (family member, friend, co-worker) that would know how to get in touch with you if CCS is unable to contact you:
  21. REMEMBER to contact CCS with address and phone number changes in order to assure that we can contact you.

    PLEASE BE SURE to contact CCS every 60 days or less to update your name on the waitlist. Failure to do so will result in your name being taken off the waitlist.

  22. Leave This Blank:

  23. This field is not part of the form submission.