Parent Intake Form
Please answer the questions below so that we can see if you qualify for the childcare assistance program. By answering these questions we can also make sure that you are given the correct forms to complete so that we can process your paperwork in a quick and efficient way. Thank you.
Which Location are you applying for
*
Please Select
Baby Toddler Nursery
Teen Baby Nursery
Doorway to Learning D65
Toddler Town Evanston
Toddler Town Chicago
Client Name
*
First Name
Last Name
Please enter your Birthday (the parent) we use this information to help look up your childcare case if you have one and you do not know your case number.
*
-
Month
-
Day
Year
Date
Do you currently have an active case with Subsidy
*
Please Select
Yes
No
Not Sure
If you know your case number enter it here if not please respond with NA
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Child's Name
*
First Name
Last Name
In order to see if you qualify for Childcare Assistance we need to ask you a few questions. 1) Are you employed ?
*
Please Select
Yes
No
Approximately how many hours a week do you work Monday to Friday - Between the hours of 6am to 7pm ? If not working please respond with not currently working or searching for employment or in school full-time.
*
What is your Hourly Pay ?
*
What is your Family Size - Please count yourself, your child(ren) you are seeking care for and anyone else in your immediate household. Only count members you legally care for or spend more then 50% of your income to support
*
Please list the names of the family members, their relationship to you and their age; that you listed in your family size above. Please note if there is another parent in the household we will also need to see their income when uploading your check stubs
*
Example - John Smith - Son - Age 5
Do you receive any other cash assistance such as Child Support payments or assistance from other family members
*
Please Select
Yes
No
If you answered yes, please list this amount.
*
Please list who the cash assistance is from
*
Please Select
Family Member
TANF
Social Security
Child Support
Unemployment
Social Security Supplemental Income
Alimony
Does Not Apply to Me
File Upload - Please upload your 2 Most current Check Stubs . If there is another parent in the household we will need to see their income as well to give you the most complete picture we can.
Browse Files
Drag and drop files here
Choose a file
By uploading your check stubs - we can give you an exact amount of what your co-pay could be. This is not required at this point but will be required with your application for childcare assistance.
Cancel
of
Submit
Should be Empty: