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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