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Application
Chris Foster
2024-02-05T07:58:43-06:00
Parent Application
Step 1 of 7
14%
PRIM ID
Do I qualify for Child Care Services?
Do you live in Tarrant County, Texas
*
Yes
No
Household Employment Status
*
Single Parent Household - You are currently working and/or in training for a minimum of 25 total hours per week or more.
Single Parent Household - You are seeking employment and plan to find work within the next 90 days.
Two Parent Household - You and your spouse are BOTH currently working and/or training for a minimum of 50 combined hours each week or more.
Two Parent Household - You and your spouse are BOTH currently seeking employment and plan to find work within the next 90 days.
Two Parent Household - You or your spouse are currently working and the other is planning to find work within the next 90 days.
Other Household Arrangement
Please select your total family income status
*
$ 0 - $ 4,971
$ 4,972 - $ 6,141
$ 6,142 - $ 7,311
$ 7,312 - $ 8,481
$ 8,482 - $ 9,650
$ 9,651 - $ 9,870
$ 9,871 - $ 10,089
$ 10,090 - $ 10,308
$ 10,309 - $ 10,528
$ 10,529 - $ 10,747
$ 10,748 - $ 10,966
$ 10,967 - $ 11,186
$ 11,187 - $ 11,405
$ 11,406 - $ 11,624
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
Are you enrolled in the Pre-K Today Program?
*
Yes
No
Are you participating in the Padua Program through Catholic Charities?
*
Yes
No
Are you enrolled in the Prime Program?
*
Yes
No
Are you participating in the Stay the Course Program through Catholic Charities?
*
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.
Personal Information
Name
*
First
Last
Date of Birth
*
Last Four digits of your Social Security Number (Optional)
Are you a teen parent in high school?
*
Yes
No
Are you a veteran?
*
Yes
No
Are you (or your spouse) currently on military deployment?
*
Yes
No
Were you in foster care as a child, and currently under the age of 24?
*
Yes
No
Relationship Status
*
Single
Married
Divorced
Other
Spouse/Other's Name
*
First
Last
Spouse/Other's Date of Birth
*
Contact Information
Mailing Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If your Physical Address different?
Physical Address is different from Mailing Address
Physical Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Employment Information
Are you currently registered with WIT (Work in Texas)?
*
Yes
No
Not sure or Other
Please provide your WIT ID:
*
Are you employed?
*
Yes
No
Warning! If you are not currently employed, you must be either seeking employment, attending school, taking training courses, or be registered with a homeless agency to qualify for services.
Employer Name
*
Hourly Pay Rate
*
Number of hours worked Per week
*
Please enter a value between
1
and
168
.
Monthly overtime, incentive or commission pay
Employment Information (SPOUSE/OTHER)
Is your Spouse/Other employed?
*
Yes
No
Spouse's Employer Name
*
Spouse's Numbers of hours worked Per week
*
Please enter a value between
0
and
168
.
Spouse's Hourly Pay Rate
*
Spouse's Monthly overtime, incentive or commission pay
School / Training
Are you attending school or taking training courses?
*
Yes
No
Institution Name
*
Number of Hours Enrolled
*
Please enter a value between
1
and
168
.
Warning! If you are not attending school or taking classes, you must be either be employed, seeking employment, or be registered with a homeless agency to qualify for services.
Child Information
Do you have a child with a diagnosed disability that needs childcare?
*
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
Review Information
Summary
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10/08/2024
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By signing this document, you agree to the following statement:
*
I certify that all information provided on this form is true and accurate. I understand that giving false information may constitute fraud and could result in prosecution.
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