Name of the Child Care Center
Child 1: First Name
*
Child 1: Last Name
*
Child 1: Date of Birth
*
-
Month
-
Day
Year
Date
Child 1: Beginning Date of Child Care
-
Month
-
Day
Year
Date
Child 1: Schedule: Monday
Child 1: Schedule: Tuesday
Child 1:Schedule: Wednesday
Child 1: Schedule: Thursday
Child 1: Schedule: Friday
Child 1: Meals your child receives:
Breakfast
Lunch
Snack
Child 2: First Name
Child 2: Last Name
Child 2: Date of Birth
-
Month
-
Day
Year
Date
Child 2: Beginning Date of Child Care
-
Month
-
Day
Year
Date
Child 2: Monday Schedule
Child 2: Tuesday Schedule
Child 2: Wednesday Schedule
Child 2: Thursday Schedule
Child 2: Friday Schedule
Child 2: Meals Provided
Breakfast
Lunch
Snack
INFANTS ONLY: Your center is required to provide Iron-Fortified Infant Formula (IFIF). The IFIF provided by ABC123 is whatever is available for purchase or Similac Sensitive Brand. You have the option of providing your own IFIF, breastmilk, or breastfeeding on-site. Please choose your preference:
I want the center to provide formula for my infant
I will provide formula for my infant
I will provide breastmilk for my infant
I will breastfeed my infant at the center
If you choose to provide formula, please list the brand here:
Parent 1 Signature
Parent 1: Date Signed
-
Month
-
Day
Year
Date
Parent 1 Name
First Name
Last Name
Parent 1: Phone
Please enter a valid phone number.
Parent 1: Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Income Verification
Please list all the children in the household
Child 1: Full Name
First Name
Last Name
Child 1: Date of Birth
-
Month
-
Day
Year
Date
Is this child enrolled?
Enrolled
Is this a foster child?
Foster Child
Please select Child 1 race and ethnicity:
Hispanic/Latino
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Child 2: Full Name
First Name
Last Name
Child 2: Date of Birth
-
Month
-
Day
Year
Date
Child 2: Enrolled?
Enrolled
Child 2: Foster?
Foster
Child 2: Race and Ethnicity
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Child 3: Full Name
First Name
Last Name
Child 3: Date of Birth
-
Month
-
Day
Year
Date
Child 3: Enrolled?
Enrolled
Child 3: Foster?
Foster
Child 3: Race and Ethnicity
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Child 4: Full Name
First Name
Last Name
Child 4: Date of Birth
-
Month
-
Day
Year
Date
Child 4: Enrolled?
Enrolled
Child 4: Foster?
Foster
Child 4: Race and Ethnicity
Hispanic/Latino
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Do any of your household members participate in SNAP, MFIB, FDPIR, TANIF?
If no, please skip to next section.
SNAP Number
SNAP
MFIB
FDPIR
SNAP Case Number
MFIB Case Number
FDPIR Case Number
Please list all income for all household members
Child Income:
Child Income
Weekly
Bi-Weekly
Twice a Month
Monthly
Adult 1: Full Name
First Name
Last Name
Adult 1: Gross Pay from W2 Employment
Gross pay BEFORE TAXES
Adult 1: W2 Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Annually
Adult 1: Self Employment Income Annually
Net income after business expenses. ANNUAL.
Adult 1: Public Assistance, Child Support, Alimony Income
Adult 1: Public Assistance, Child Support, Alimony Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Adult 1: All other income
Pension, Retirement, Disability, Unemployment, Veterans Benefits, etc.
Adult 1: Other Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Adult 2: Full Name
First Name
Last Name
Adult 2: Gross Pay from W2 Employment
Gross pay BEFORE TAXES
Adult 2: W2 Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Annually
Adult 2: Self Employment Income Annually
Net income after business expenses. ANNUAL.
Adult 2: Public Assistance, Child Support, Alimony Income
Adult 2: Public Assistance, Child Support, Alimony Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Adult 2: All other income
Pension, Retirement, Disability, Unemployment, Veterans Benefits, etc.
Adult 2: Other Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Adult 3: Full Name
First Name
Last Name
Adult 3: Gross Pay from W2 Employment
Gross pay BEFORE TAXES
Adult 3: W2 Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Annually
Adult 3: Self Employment Income Annually
Net income after business expenses. ANNUAL.
Adult 3: Public Assistance, Child Support, Alimony Income
Adult 3: Public Assistance, Child Support, Alimony Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
Adult 3: All other income
Pension, Retirement, Disability, Unemployment, Veterans Benefits, etc.
Adult 3: Other Income Frequency
Weekly
Bi-Weekly
Twice a Month
Monthly
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Signature Page
Please sign below.
Last 4 of Parent 1 Social Security Number
Check this box if you do not have a social security number:
I do not have a social security number
Parent 1: Signature
Parent 1: Full Name
First Name
Last Name
Parent 1: Signature Date
-
Month
-
Day
Year
Date
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FOR OFFICE USE ONLY
FOR ABC123 OFFICE USE ONLY
Approved:
A-Foster
A-Case Number
A-Income
B
C
Household Members
Total Income
Per
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Nicole Flick Signature
Nicole Flick-Date Signed
-
Month
-
Day
Year
Date
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