Disaster Relief Application

PRIM ID
Do I qualify for Child Care Services?
Have you received child care assistance at any time within the last 12 months?*
- Yes
- No
Household Status*
- Single Parent Household
- Two Parent Household
- Other Household Arrangement
Please select your total family income status*
- $ 0 - $ 2,626
- $ 2,627 - $ 3,435
- $ 3,436 - $ 4,243
- $ 4,244 - $ 5,051
- $ 5,052 - $ 5,859
- $ 5,860 - $ 6,667
- $ 6,668 - $ 6,819
- $ 6,820 - $ 6,970
- $ 6,971 - $ 7,122
- $ 7,123 - $ 7,273
- $ 7,274 - $ 7,425
- $ 7,426 - $ 7,576
- $ 7,577 - $ 7,728
- $ 7,729 - $ 7,879
- $ 7,880 - $ 8,031
- OTHER
Do you meet the monthly income guidelines? (This includes ALL income received on a monthly basis before taxes have been taken out)
Are you Homeless?*
- Yes
- No
Are you registered with a homeless assistance agency?*
- Yes
- No
How many people are in your Family?*
Please enter a value greater than or equal to 1.
This should include yourself and any children, but only family currently living in your household.
I'm sorry, you do not meet the minimal requirements to apply for CCMS services at this time. If you have any questions, please call our customer service number at (817) 831-0374 for assistance.
Congratulations you may be eligible to apply for our services! Please Continue.

Contact Information
Mailing Address*
Street Address City State ZIP Code
If your Physical Address different?
- Physical Address is different from Mailing Address
Physical Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone
Contact Email*
Enter Email Confirm Email
How do you preferred to be contacted by our office?*
- Email
- USPS Mail
- Phone Call

Child Information
Do you have a child with special needs?*
- Yes
- No
Please list all of your children and specify if they require child care.*
First Name Last Name Date of Birth Disability Needs Care
Yes Yes

Do I qualify for Child Care Services?