Application

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 employed?*
- Yes
- No
Warning! If you are not currently employed, you must be either 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.
I'm sorry, you do not meet the minimal requirements to apply for CCMS services at this time. You must either be gainfully employed, registered with a homeless agency, or you must be in school/training to qualify. If you have any questions, please call our customer service number at (817) 831-0374 for assistance.

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?