Skip to content
Welcome to Tarrant County CCMS
|
817-831-0374
HOME
PARENTS
PROVIDERS
CONTACT US
SURVEY
Providers
Get Assistance
Disaster Relief Application
Logan Crouch
2017-09-07T13:59:27-05:00
Parent Application - Disaster Relief
Step 1 of 5
20%
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.
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
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
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
{all_fields}
Go to Top