Child Care Bridge Fund Application

CCBF is available for families in Chippewa & Eau Claire counties.
Parent or Guardian Information
Applicant Name*
Previous/Maiden Name (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Gender*
Marital Status*

SingleMarriedSeparatedDivorced
Number of Persons Dependent upon Family Income for Support*
Please list the total number of household members.
Children Eligible for Child Care:

Please provide information for each child enrolled in child care program:*

	Child's Name	Child's Age	Typical days & times child care is used
1
2
3
4

Child Care Program Information

Please provide the information requested about your child care program/provider where your children are enrolled. To qualify, child care program must be state licensed or county certified & a participant in the YoungStar Program.
Child Care Program or Provider's Name*
Address
Phone Number
As of today, what is your current past due balance with your child care provider:*
Have you applied for Wisconsin Shares Child Care Assistance?*

NoYes
Are you currently receiving Wisconsin Shares?*

NoYes
If you were denied for Wisconsin Shares, please tell us why
Income in Your Family – Attach proof of wages

To quality for this program, a family's income must fall within 185-300% Federal Poverty Level (FPL). Families will need to provide proof of income or a denial/ineligibility documentation for Wisconsin Shares. The chart below lists the income range by family size that your family must fall within.

List all income for your household. This includes earned wages, self-employment, etc and unearned SSI, child support, disability, etc income*

Attach proof for all income listed above for the previous 30 days. This may include paystubs, unemployment, child support, social security or disability benefit letters, etc. You may also include a letter or proof of denial of Wisconsin Shares benefits.

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Please provide a brief, but detailed story describing your current situation and reasons why your struggling to pay for child care these stories are shared anonymously with our funders to help show the need for this program. Thank you!
I understand that...
- the statements made in this application must be and are to the best of my knowledge, true and correct.
- all information provided will be verified.
- CCP staff will be in contact with child care program listed above about your account & past due balance.
Signature*

Clear
Once your application is submitted, a representative from Child Care Partnership will be contacting you for a short follow-up survey.
Should be Empty:

CCBF is available for families in Chippewa & Eau Claire counties.