Child Care Application and Authorization

Authorization

If update, change in:

FROM: (Print Worker Name)

Unit, Number & Address: City, Zip Code

Child Care Application and Authorization

INITIAL AUTHORIZATION

REDETERMINATION

Hours

Children

Address

Eligibility Extension

Termination of Care

4C Agency

DCF

Welfare Transition Contracted Provider

Privatization Provider

UPDATE Custody Worker/Unit

SECTION A: CLIENT/FAMILY INFORMATION

Social Security Number

Last Name First Name MI (Print)

one):

Parent/Guardian/Foster Parent/Caregiver (Circle applicable

Date of Birth

Sex

Race

Social Security Number

Spouse or other Parent (if applicable) (Print): Last Name First Name MI

Date of Birth

Sex

Race

Address

City

State Zip

Day Time Phone No.

Evening Phone No.

If there is NO spouse: enter the Marital Status: Single

Parent/ (if different from above): Last Name First Name MI (Print)

Address

City

Divorced

Widowed Separated

Social Security Number

State Zip

Day Time Phone No.

Date of Birth

Sex

Race

Evening Phone No.

SECTION B: ELIGIBILITY

I. Status:

Assistance

At Risk: { PI

{ PS { FC

Non-Assistance

School Readiness Eligible Child

Project Safety Net

In Home

Welfare Transition (WT):

Out of Home: Relative/Non-Relative Foster Care

{ Applicant

{ Recipient

RFA #

{ Unemployed Parent

{ Refugee (WT)

________________________________ { Respite (WT)

TCC:

Transitional Education & Training TCC Begin Date: ___________

FOR 4C AGENCY USE ONLY

Income Eligible ................
................

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