Child Care Wait List Assessment Applicant Name (parent applying for services) * Required First Last Applicant Social Sercurity Number (optional)Gender * RequiredMaleFemaleDate of Birth - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Physical Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code County * Required(select)ArmstrongBriscoeCarsonCastroChildressCollingsworthDallamDeaf SmithDonleyGrayHallHansfordHartleyHemphillHutchinsonLipscombMooreOchiltreeOldhamParmerPotterRandallRobertsShermanSwisherWheelerOtherIs your Mailing Address different than your Physical Address listed above? * RequiredYesNoMailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email Address (optional) Phone * RequiredIs there a 2nd Parent residing in your household? * RequiredYesNo2nd Parent - Name * Required First Last 2nd Parent - Social Security Number (optional)2nd Parent - Gender * RequiredMaleFemale2nd Parent - Date of Birth - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY I am requesting Child Care Services in order to work or attend a job training or educational program for a combination of at least an average of 25 hours per week for a single parent home or a combination of at least an average of 50 hours per week for a 2 parent home * RequiredYesNoMy total assets exceeds $1,000,000 * RequiredYesNo Income Eligibility Requirements Family Monthly Income Guidelines Income Eligibility Guidelines - 10/01/2019 - 9/30/2020 Family Size85% SMI Monthly Income Range Gross Amount2$37753$46634$55525$64406$73287$74958$76619$782810$799411$816112$8327 My family total monthly gross income is under the income limit listed above, based on family size * RequiredYesNoAre you currently receiving child care assistance from a different area of Texas? * RequiredYesNoStatus * RequiredSelect all options that apply to you. I am a qualified veteran I am an eligible foster youth I am homeless I am a parent on military deployment I am teen parent I am a parent whose child has a disability None of the above Status * RequiredSelect all options that apply to you. I am a Parent participating in Workforce Solutions WIOA program I am Parent participating in Workforce Solutions NCP program I am currently receiving Child Care Services and requesting to add care for a child not currently receiving services themselves I was referred by a Workforce Solutions Partner. None of the above If referred by a Workforce Solutions Partner please list name of Referring Agency:Children Needing CareComplete information on each child needing care Child Name Child Social Security Number (optional) Child's Gender Child is a U.S. Citizen / Legal Immigrant Child has a disability Child's Date of Birth Edit Delete There are no Children. Add Child Maximum number of children reached. By signing below, I understand it is my responsibility to complete and submit this assessment to Child Care Services every 60 days and to report any changes to this assessment by completing and submitting it again to keep my name on the wait list. By not completing and submitting this form every 60 days, I am authorizing Child Care Services to remove my name from the wait list * RequiredType your Full Name below to E-Sign this document.