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Initial Evaluation of Eligibility

  1. Are you?

  2. Please list the names, dates of birth and Social Security Numbers of each adult in the household, including yourself.

  3. Are you employed for at least 25 hours per week?

  4. Please name the place of employment for each adult, including yourself.

  5. Please list the hourly rate, hours per week, and how often paid for each adult, including yourself

  6. Monthly / Weekly, etc.

  7. Please enter the monthly amount of any other assistance or income currently being received.

  8. Are you enrolled in school or training?

  9. What is your school / training schedule?

  10. Do you have a cumulative grade point average (GPA) of 2.0 or above?

    You will have to provide verification of your GPA upon review of eligibility for possible enrollment.

  11. Are you a veteran?

  12. Please list the names, date(s) of birth, and Social Security number(s) for the child(ren) who need childcare.

  13. List any other children who do not need childcare and give their date(s) of birth and Social Security number(s).

  14. Have you received childcare through Child Care Services before?

  15. It is not mandatory that you answer the following questions, however it would be helpful in providing services to your family.

  16. Has your child received Early Childhood Intervention services (ECI)?

  17. Does your child have a special education or resource teacher?

  18. Does the child(ren) have any disabilities or special needs?

  19. Do you have any other family needs?

  20. Are you interested in receiving family enrichment services?

  21. Can we give your name and number to a Family Enrichment Service?

  22. Please be sure to contact us every 60 days or less to update your child(ren) on the wait list in order to avoid being taken off of the wait-list.

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