Application

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 - $ 3,269
- $ 3,270 - $ 4,275
- $ 4,276 - $5,282
- $ 5,283 - $6,288
- $ 6,289 - $ 7,294
- $ 7,295 - $ 8,300
- $ 8,301 - $ 8,489
- $ 8,490 - $ 8,678
- $ 8,679 - $ 8,866
- $ 8,867 - $ 9,055
- $ 9,056 - $ 9,244
- $ 9,245 - $ 9,432
- $ 9,433 - $ 9,621
- $ 9,811 - $ 9,999
- 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 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
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

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 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

Review Information
Summary

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06/02/2023
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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.

Parent Application

Step 1 of 7

Do I qualify for Child Care Services?

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

Contact Information

Employment Information

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.

Employment Information (SPOUSE/OTHER)

School / Training

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

Review Information

Summary

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