CCR Baby Promise Pre-Application

CCR Baby Promise Pre-Application

Puede traducir este formulario con la bandera de idiomas en la esquina derecha
Baby Promise provides fully-funded quality child care for children from ages six weeks to three years through multiple licensed providers in Crook, Deschutes and Jefferson counties and the Confederated Tribes of Warm Springs.
Disclosure: Participation in Baby Promise is subject to income eligibility and availability of spots. Child care is not available in all cities; child care providers must be a pre-approved Baby Promise provider. This application does not guarantee participation or eligibility in the Baby Promise Program.

I have read and understand the above disclosure
Referred by:
Child's Name *

First Name Last Name
Child's Date of Birth *

Month Day Year
Date
Child's Age *
Parent/Guardian Name *

First Name Last Name
Child's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Email *
example@example.com
Preferred Method of Contact *

Email Phone Text
Preferred language *
Family size (all persons living in household) *
Do any of the below apply to your family?

ERDC TANF SNAP Homeless
Parent/Guardian employment status (check all that apply):

Employed PT/FT Student PT/FT Specialized jobs training Unemployed Other
Please describe:
Estimated income for past 60 days *
What city do you need care in? *
What is the earliest date you need care on? *

Month Day Year
Date
Should be Empty: