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Household Information. * Print Full Name: Date: * Address: * Language: * Date of Birth: * Gender: F M

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KinderWaitlist Application

Household Information Required fields are marked with *

* Print Full Name: _________________________________________________ Date: ______________ * Address: ___________________________________________________________________________

Street Apartment/Unit

____________________________________________________________________________________

City State Zip Code

* Language: ______________________ * Date of Birth: _______________ * Gender: F M Social Security Number: _____-_____-______ Declined to provide SSN

Home Number: (____) _____-_____Work Number: (____) _____-______Cell Number: (____) ____-____

Best time to be called: Morning Afternoon Evening * Okay to call work phone: Yes No Email Address: ________________________________ Zip Code of area child care is preferred_______

* Single Parent: Yes No * Married: Yes No * Speak English Yes No Ethnicity: American Indian or Alaskan Native Asian Black or African American Caucasian

Native Hawaiian or Other Pacific Islander Other

Household Information Required fields are marked with *

* Print Full Name: _________________________________________________ Date: ______________ * Address: ___________________________________________________________________________

Street Apartment/Unit

____________________________________________________________________________________

City State Zip Code

* Language: ______________________ * Date of Birth: _______________ * Gender: F M Social Security Number: _____-_____-______ Declined to provide SSN

Home Number: (____) _____-_____Work Number: (____) _____-______Cell Number: (____) ____-____

Best time to be called: Morning Afternoon Evening * Okay to call work phone: Yes No Email Address: ________________________________ Zip Code of area child care is preferred_______

* Single Parent: Yes No * Married: Yes No * Speak English Yes Ethnicity: American Indian or Alaskan Native Asian Black or African American Caucasian

Native Hawaiian or Other Pacific Islander Other

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Parent 1 Activity

Employment Retired Caregiver Age 65 and Over

Education or Training TAFDC Recipient/Household Special Need of Child Receiving Services from DCF Special Need of Parent Seeking Employment

Parent 2 Activity

Employment Retired Caregiver Age 65 and Over

Education or Training TAFDC Recipient/Household Special Need of Child Receiving Services from DCF Special Need of Parent Seeking Employment

Employment / Training Details (Parent 1) Please Circle One: Employment Education Training Name of Location: ________________________________________

Address: ________________________________ _______________________ _______ ________

Street City State Zip Code

Schedule:

Mon Tue Wed Thurs Fri Sat Sun Start time: _______ _______ _______ _______ _______ _______ ______ End time: _______ _______ _______ _______ _______ _______ ______

Employment / Training Details (Parent 2) Please Circle One: Employment Education Training Name of Location: ________________________________________

Address: ________________________________ _______________________ _______ ________

Street City State Zip Code

Schedule:

Mon Tue Wed Thurs Fri Sat Sun Start time: _______ _______ _______ _______ _______ _______ ______ End time: _______ _______ _______ _______ _______ _______ ______

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Parent Income (Parent 1)

Income Type Gross Monthly Income Type Gross Monthly Other $________________ Federal Benefit $____________ Employment $________________ Child Support $____________ Self Employment $________________ Housing $____________

TANF / TAFDC $________________ SSI $____________

Food Stamps $________________ Child Support Paid (Subtracted) $_________

Parent Income (Parent 2)

Income Type Gross Monthly Income Type Gross Monthly Other $________________ Federal Benefit $____________ Employment $________________ Child Support $____________ Self Employment $________________ Housing $____________

TANF / TAFDC $________________ SSI $____________

Food Stamps $________________ Child Support Paid (Subtracted) $_________ Child Information

Required fields are marked with *

* This Child Requires Care: Yes No Family Type: Natural Foster Guardian

* First Name: __________________________Middle Name: ________________Last________________ No middle name * Date of Birth: ____/____/_______ * Gender: Female Male

School District: _________________________ School Currently Attending: _______________________ Current School Grade: ______ Social Security Number: _____-_____-_____ Declined to provide SSN Ethnicity: American Indian or Alaskan Native Asian Black or African American Caucasian

Native Hawaiian or Other Pacific Islander Other Childs Needs and Schedule:

Needs (select if applicable): Special Need Evening Schedule (select one or more): Full Time Weekend

Part Time Overnight

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Priority Codes for child needing care:

General Priority Child of Foster Care Grandparent/Guardian Families Parent with Special Needs Homeless Family Child of Military Personnel Child of Teen Parent Child with Special Needs Continuity of Care: Aging out Continuity of Care: Approved Break in Service

Continuity of Care: Geographic Relocation Continuity of Care: Homeless Contract Continuity of Care: NTCC Continuity of Care: Supportive Referral Continuity of Care: Teen Parent Contract

Sibling: Contract Sibling: Voucher Summer only care

Preferred Program: IE DHCD/DTA Shelter Teen Parent Head Start DCF

Supportive Early Head Start Homeless

Preferred Child Care Provider: _________________________________________

Child Information Required fields are marked with *

* This Child Requires Care: Yes No Family Type: Natural Foster Guardian * First Name: __________________________Middle Name: ________________Last________________

No middle name * Date of Birth: ____/____/_______ * Gender: Female Male School District: _________________________ School Currently Attending: _______________________ Current School Grade: ______ Social Security Number: _____-_____-_____ Declined to provide SSN Ethnicity: American Indian or Alaskan Native Asian Black or African American Caucasian

Native Hawaiian or Other Pacific Islander Other Childs Needs and Schedule:

Needs (select if applicable): Special Need Evening Schedule (select one or more): Full Time Weekend

Part Time Overnight Date Child Care is needed: ____________________

Priority Codes for child needing care:

General Priority Child of Foster Care Grandparent/Guardian Families Parent with Special Needs Homeless Family Child of Military Personnel Child of Teen Parent Child with Special Needs Continuity of Care: Aging out Continuity of Care: Approved Break in Service

Continuity of Care: Geographic Relocation Continuity of Care: Homeless Contract Continuity

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of Care: NTCC Continuity of Care: Supportive Referral Continuity of Care: Teen Parent Contract Sibling: Contract Sibling: Voucher Summer only care

Preferred Program: IE DHCD/DTA Shelter Teen Parent Head Start DCF

Supportive Early Head Start Homeless

Preferred Child Care Provider: _________________________________________

Child Information Required fields are marked with *

* This Child Requires Care: Yes No Family Type: Natural Foster Guardian * First Name: __________________________Middle Name: ________________Last________________

No middle name * Date of Birth: ____/____/_______ * Gender: Female Male School District: _________________________ School Currently Attending: _______________________ Current School Grade: ______ Social Security Number: _____-_____-_____ Declined to provide SSN Ethnicity: American Indian or Alaskan Native Asian Black or African American Caucasian

Native Hawaiian or Other Pacific Islander Other Childs Needs and Schedule:

Needs (select if applicable): Special Need Evening Schedule (select one or more): Full Time Weekend

Part Time Overnight Date Child Care is needed: ____________________

Priority Codes for child needing care:

General Priority Child of Foster Care Grandparent/Guardian Families Parent with Special Needs Homeless Family Child of Military Personnel Child of Teen Parent Child with Special Needs Continuity of Care: Aging out Continuity of Care: Approved Break in Service

Continuity of Care: Geographic Relocation Continuity of Care: Homeless Contract Continuity of Care: NTCC Continuity of Care: Supportive Referral Continuity of Care: Teen Parent Contract

Sibling: Contract Sibling: Voucher Summer only care

Preferred Program: IE DHCD/DTA Shelter Teen Parent Head Start DCF

Supportive Early Head Start Homeless

Preferred Child Care Provider: _________________________________________

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