Childcare Resources of Indian River

Childcare Resources of Indian River Preliminary Application

Thank you for your interest in Childcare Resources of Indian River. We are currently accepting applications for the 2011-2012 school year. To be placed on our waiting list, please complete the following information and return it to us as soon as possible. You must reside in Indian River County and be employed a minimum of 30 hours per week or be a full time student to apply for assistance.

If you change addresses or phone numbers, please notify our office immediately.
If we cannot reach you when an opening occurs because you have moved or changed phone numbers, you may lose your spot.

Section 1: General Information
Applicants name

How many dependent children are living in your family household?

If married, are both you and your spouse employed 30 or more hours weekly or full-time students?	Yes No

If single, are you employed 30 or more hours weekly or a full-time student?	Yes No

Section 2: Child or children's Information
First child's full name

Child's Birthday

Age

Sex	Boy Girl

Child resides with	Mother Father Both

or Other

Race

Second child's full name

Child's Birthday

Age

Sex	Boy Girl

Child resides with	Mother Father Both

or Other

Race

Section 3: Mother's information
Mother's name

Status	Married Single

Home phone

Work phone

Cell phone

email

Mailing Address

Hours worked per week

Wages earned per week (before taxes)

Annual Wages (before taxes)

Child support/alimony you receive per month

Other income received each month (food stamps, social security benefits, unemployment, etc.)

If student:	Full time Part time

Section 4: Father's information
Father's name

Status	Married Single

Home phone

Work phone

Cell phone

Email

Mailing address

Hours worked per week

Wages earned per week (before taxes)

Annual Wages (before taxes)

Child support/alimony you receive per month

Other income received each month (food stamps, social security benefits, unemployment, etc.)

If student:	Full time Part time

How did you hear about us?

Verification No.: