Child Care Wait List Assessment Applicant Name (parent applying for services) * Required First Last Applicant Social Security Number (optional) Gender * Required Male Female Date of Birth * Required MM slash DD slash YYYY Physical Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code County * Required(select)ArmstrongBriscoeCarsonCastroChildressCollingsworthDallamDeaf SmithDonleyGrayHallHansfordHartleyHemphillHutchinsonLipscombMooreOchiltreeOldhamParmerPotterRandallRobertsShermanSwisherWheelerIs your Mailing Address different than your Physical Address listed above? * Required Yes No Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address * Required Phone * RequiredIs there a 2nd Parent residing in your household? * Required Yes No 2nd Parent – Name * Required First Last 2nd Parent – Social Security Number (optional) 2nd Parent – Gender * Required Male Female 2nd Parent – Date of Birth * Required MM slash DD slash YYYY I am requesting Child Care Services in order to search for work * Required Yes No 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 * Required Yes No My total assets exceeds $1,000,000 * Required Yes No Income Eligibility Requirements Family Monthly Income Guidelines Income Eligibility Guidelines – 10/01/2022 – 9/30/2023 Family Size 85% SMI Monthly Income Range Gross Amount 2 $4276 3 $5283 4 $6289 5 $7295 6 $8301 7 $8490 8 $8679 9 $8867 10 $9056 11 $9245 12 $9433 My family total monthly gross income is under the income limit listed above, based on family size * Required Yes No Are you currently receiving child care assistance from a different area of Texas? * Required Yes No Priority Group * RequiredDocumentation will be required for EACH selected priority groups. I am a qualified veteran I am a qualified spouse I am an eligible foster youth I am homeless I am a parent on military deployment I am currently a teen parent (18 years old or younger, or 19 years old and attending high school or the equivalent) I am a parent whose child has a disability I am a Parent participating in Workforce Solutions Training Services 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. I am currently receiving Child Care Services in another Texas city and will be moving to the Panhandle area None of the above HiddenStatus * RequiredSelect all options that apply to you. I am a Parent participating in Workforce Solutions Training Services 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. I am currently receiving Child Care Services in another Texas city and will be moving to the Panhandle area 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.
