Child Care Assistance Screening Form
A. Tell us about your child care needs
*Required questions are marked with a red asterisk*
Are you currently employed? (If yes, you MUST attach a current pay stub)
*
Yes
No
If Yes, please include employer name and how many hours you usually work each week:
If working, what is your hourly rate of pay?
Are you currently in school? (If yes, you MUST attach a current class schedule)
*
Yes
No
If Yes, please include school name and how many hours attended each week:
Is the other parent of any of the children listed living in the home?
*
Yes
No
If Yes, is that parent currently working or in school? If yes, you MUST attach current pay stub or class schedule.
Yes
No
If Yes, please indicate which and how many hours each week:
If working, what is the other parent's hourly rate of pay?
If all parents/responsible adults in the home are not currently working or in school, please briefly describe any extenuating circumstances as to why child care is needed here:
Does your household receive any other sources of income?
*
Yes
No
If Yes, please describe the type of income and the monthly amount received:
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B. Tell Us About Yourself
*Required questions are marked with a red asterisk*
Parent/RA
*
First Name
Last Name
Verify Current Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Verify Current Residence Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
What type of phone is this?
*
Cell Phone
Home Phone
Work Phone
Email Address
example@example.com
Is your current address a temporary living arrangement?
*
Yes
No
If you answered 'Yes', what type of living arrangement do you have?
Adult Relative
Homeless or Emergency Shelter
Hotel or Motel
Lack Fixed Nighttime Address
Non Relative
Place not designated for sleeping
Shelter for Battered Women and Children
Supervised Shelter
Hospital for 30 days or under
Psychiatric hospital for 30 days or under
Unknown
Gender :
*
Female
Male
Marital Status
*
Single
Married
Divorced
Widowed
Separated 12 Months or more
Separated 12 Months or less
Ethnicity
*
Hispanic Cuban
Hispanic Mexican American
Hispanic Puerto Rican
Hispanic Other
Not Hispanic or Latino
Unreported
Race
*
American Indian or Alaskan Native
Black/African/American
Hawaiian or Pacific Islander
White/Caucasian
Unreported
Preferred Language
*
English
Spanish
Other
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C. TELL US ABOUT YOUR CHILDREN
*Required questions are marked with a red asterisk*
First Child's Name
*
First Name
Last Name
First Child's Age
*
First Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender :
*
Female
Male
Child Enrolled in:
Head Start
NC Pre-K
Ethnicity
*
Hispanic Cuban
Hispanic Mexican American
Hispanic Puerto Rican
Hispanic Other
Not Hispanic or Latino
Unreported
Race
*
American Indian or Alaskan Native
Black/African/American
Hawaiian or Pacific Islander
White/Caucasian
Unreported
Preferred Language
*
English
Spanish
Other
Second Child
Child's Name
First Name
Last Name
Child's Age
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender :
Female
Male
Child Enrolled in:
Head Start
NC Pre-K
Ethnicity
Hispanic Cuban
Hispanic Mexican American
Hispanic Puerto Rican
Hispanic Other
Not Hispanic or Latino
Unreported
Race
American Indian or Alaskan Native
Black/African/American
Hawaiian or Pacific Islander
White/Caucasian
Unreported
Preferred Language
English
Spanish
Other
Third Child
Child's Name
First Name
Last Name
Child's Age
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender :
Female
Male
Child Enrolled in:
Head Start
NC Pre-K
Ethnicity
Hispanic Cuban
Hispanic Mexican American
Hispanic Puerto Rican
Hispanic Other
Not Hispanic or Latino
Unreported
Race
American Indian or Alaskan Native
Black/African/American
Hawaiian or Pacific Islander
White/Caucasian
Unreported
Preferred Language
English
Spanish
Other
Fourth Child
Child's Name
First Name
Last Name
Child's Age
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender :
Female
Male
Child Enrolled in:
Head Start
NC Pre-K
Ethnicity
Hispanic Cuban
Hispanic Mexican American
Hispanic Puerto Rican
Hispanic Other
Not Hispanic or Latino
Unreported
Race
American Indian or Alaskan Native
Black/African/American
Hawaiian or Pacific Islander
White/Caucasian
Unreported
Preferred Language
English
Spanish
Other
Fifth Child
Child's Name
First Name
Last Name
Child's Age
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender :
Female
Male
Child Enrolled in:
Head Start
NC Pre-K
Ethnicity
Hispanic Cuban
Hispanic Mexican American
Hispanic Puerto Rican
Hispanic Other
Not Hispanic or Latino
Unreported
Race
American Indian or Alaskan Native
Black/African/American
Hawaiian or Pacific Islander
White/Caucasian
Unreported
Preferred Language
English
Spanish
Other
Sixth Child
Child's Name
First Name
Last Name
Child's Age
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender :
Female
Male
Child Enrolled in:
Head Start
NC Pre-K
Ethnicity
Hispanic Cuban
Hispanic Mexican American
Hispanic Puerto Rican
Hispanic Other
Not Hispanic or Latino
Unreported
Race
American Indian or Alaskan Native
Black/African/American
Hawaiian or Pacific Islander
White/Caucasian
Unreported
Preferred Language
English
Spanish
Other
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Does any child in your home have a documented special need as described by an Individualized Family Service Plan (IFSP), Individualized Education Program (IEP), Personal Care Plan (PCP) or a 504 Plan?
*
Does any child in your home have a documented special need as described by an Individualized Family Service Plan (IFSP), Individualized Education Program (IEP), Personal Care Plan (PCP) or a 504 Plan?
Please Select
Yes
No
If any, please list their name here:
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SIGNATURE PAGE
Please note that in order for your form to be accepted, all required information must be included and the form must be signed.
Your Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Please note that by entering your full name you authorize the Alamance County Department of Social Services to review your information and contact you regarding your application.
*
Use your mouse to sign above.
Please upload current pay stubs or class schedule for all parents/responsible adults reported as working or in school.
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