Confidential Application for Early Learning and Care Services and Certification of Eligibility for Essential Workers

Form COVID-19 2020 Confidential Application for Early Learning and Care Services and Certification of Eligibility for Essential Workers

- Step 1 of 11

Please open the instruction pdf to help guide you along the process.
COVID-19 2020 Confidential Application Instructions

Agency Name: *

Family Identification/Case No.: *

Initial Subsidized Service Date: *

Note: State regulations require a formal application and certification for early learning and care services. This form must be completed by an agency representative in consultation with the family. The agency must certify family eligibility prior to beginning services. Refer to the attached instructions for the completion of this form.

Section I. Family Identification.

See Instructions, Section I.

If you are eligible for Emergency Childcare due to COVID-19, check this box
If you are a single parent/caretaker, check this box

Parent A

Name of parent/caretaker (full name, including middle initial) *

First

Middle

Last

Phone no. (cell or home) *

Phone no. (work/school)

Parent B

Name of parent/caretaker (full name, including middle initial)

First

Middle

Last

Phone no. (cell or home)

Phone no. (work/school)

Address Line 1

Address Line 2

City

State

Zip Code

FIPS Code

Section II. Family Income and Eligibility

1. Income and Eligibility Information

Total Family Income *

I certify that the total family income stated is true and correct. *

Parent Initials

COVID-19 Emergency Childcare Self Certification

Click or drag a file to this area to upload.

(Upload Documentation)

2. Employer Information - Must be completed for each adult listed in Section I above if the basis of need is essential worker (Attach documentation.)

Employer for Parent A *

Employer Address for Parent A *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have other employers to add?

Employer for Parent A

Employer Address for Parent A

Address Line 1

Address Line 2

City

State

Zip Code

Days and working/training hours:

Monday

Start time to end time

Tuesday

Start time to end time

Wednesday

Start time to end time

Thursday

Start time to end time

Friday

Start time to end time

Saturday

Start time to end time

Sunday

Start time to end time

Employer for Parent B

Employer Address for Parent B

Address Line 1

Address Line 2

City

State

Zip Code

Do you have other employers to add?

Employer for Parent B

Employer Address for Parent B

Address Line 1

Address Line 2

City

State

Zip Code

Days and working/training hours:

Monday

Start time to end time

Tuesday

Start time to end time

Wednesday

Start time to end time

Thursday

Start time to end time

Friday

Start time to end time

Saturday

Start time to end time

Sunday

Start time to end time

Section III. Family Size

Family size *

(See “Funding Terms and Conditions” for instructions on calculating family size.)

Section IV. Data on Children.

List ALL children residing in the home and counted in the family size.

Complete for all children residing in the home.

Full Name of Child Including Middle Initial *

First

Middle

Last

Gender *

Male
Female

Birth Date *//

Do you have more children to add? *

Full Name of Child Including Middle Initial

First

Middle

Last

Gender

Male
Female

Birth Date//

Do you have more children to add?

Full Name of Child Including Middle Initial

First

Middle

Last

Gender

Male
Female

Birth Date//

Do you have more children to add?

Full Name of Child Including Middle Initial

First

Middle

Last

Gender

Male
Female

Birth Date//

Complete only for children served by your agency

Adjustment Factor Code

Child 1

Ethnicity

Child 1

Race

Child 1

Language Code

Child 1

Child is English Learner?

School age ONLY

Adjustment Factor Code

Child 2

Ethnicity

Child 2

Race

Child 2

Child is English Learner?

School age ONLY

Adjustment Factor Code

Child 3

Ethnicity

Child 3

Race

Child 3

Child is English Learner?

School age ONLY

Adjustment Factor Code

Child 4

Ethnicity

Child 4

Race

Child 4

Child is English Learner?

School age ONLY

For children enrolled in more than one program or site, use additional lines as needed

Provider/site name

Program Code

Type of Care Code

Hours of care per day for each day of the week (for children enrolled in early child education)

Hours of care per day for each day of the week (for children enrolled in preschool)

Provider/site name

Program Code

Type of Care Code

Hours of care per day for each day of the week (for children enrolled in early child education)

Hours of care per day for each day of the week (for children enrolled in preschool)

Provider/site name

Program Code

Type of Care Code

Hours of care per day for each day of the week (for children enrolled in early child education)

Hours of care per day for each day of the week (for children enrolled in preschool)

Provider/site name

Program Code

Type of Care Code

Hours of care per day for each day of the week (for children enrolled in early child education)

Hours of care per day for each day of the week (for children enrolled in preschool)

Section V. Certification and Signature of Parent/Caretaker.

I understand that I am self-certifying single parent status under penalty of perjury. *

Parent Initials

I understand that as a condition of receiving Emergency Childcare services, I am not eligible for 12-month eligibility. *

Parent Initials

I understand that the information about my eligibility may be reviewed by representatives of the State of California, the federal government, independent auditors, or others as necessary for the administration of the program. *

Parent Initials

I understand that this certification is not complete until all documentation is submitted and this form has been signed and dated by me and reviewed, signed, and dated by an agency representative. *

Parent Initials

I certify that my family assets do not exceed $1,000,000; Child Care and Development Block Grant Act Section 658 p (4)(B). *

Parent Initials

I DECLARE UNER PENALTY OF PERJURY THAT THE ABOVE INFORMAITON IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Signature of Parent A *

First

Last

Date *

Parent A Relationship to Child: *

Parent
Grandparent
Guardian
Foster Parent
Other

If clicked other, let us know relationship below

Signature of Parent B

First

Last

Date

Parent B Relationship to Child:

Parent
Grandparent
Guardian
Foster Parent
Other

If clicked other, let us know relationship below

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