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Service Industry Recovery Child Care Enrollment Form

  1. Complete the following information for the parent or caregiver who is a Service Industry Worker in need of child care for their child(ren) in order to work.

    Please put NA for any required fields that do not apply.

  2. Applicant Information
  3. Mailing address is the same as physical address?*
  4. Gender*
  5. Race/Ethnicity*
  6. Are you a current Child Care Services (CCS) customer? *
  7. Marital Status*
  8. Consulting the chart below, is your income AT or BELOW these limits based on your family size? *
  9. SIR Income Table
  10. If your family income is above the 75% limit, you do not qualify for SIR child care and cannot apply for this program.

    Family size consists of parents, those in the home who can be claimed as dependents on a federal tax return, or a minor who is the responsibility of the parent/applicant. Income does not include federal or state assistance or child support. A family's monthly income is the gross income before adjustments are made for taxes, which can be referred to as gross earnings or gross pay.

  11. Complete the section below with information for each household member. Household members consist of spouse/partner and dependents only.

    After you submit this form, you will be contacted by Workforce Solutions staff and asked to provide additional personal information over the phone which will include which child care provider you have chosen.

  12. Spouse/Partner Information
  13. Race/Ethnicity
  14. Household Member
  15. Gender*
  16. Hispanic/Latino*
  17. Race/Ethnicity*
  18. Child Care Needed*
  19. Household Member
  20. Gender
  21. Race/Ethnicity
  22. U.S. Citizen
  23. Child Care Needed
  24. Household Member
  25. Gender
  26. Race/Ethnicity
  27. U.S. Citizen
  28. Child Care Needed
  29. Household Member
  30. Gender
  31. Race/Ethnicity
  32. U.S. Citizen
  33. Child Care Needed
  34. Household Member
  35. Gender
  36. Race/Ethnicity
  37. U.S. Citizen
  38. Child Care Needed
  39. Household Member
  40. Gender
  41. Race/Ethnicity
  42. U.S. Citizen
  43. Child Care Needed
  44. Household Member
  45. Gender
  46. Race/Ethnicity
  47. U.S. Citizen
  48. Child Care Needed
  49. Employment Information
  50. Which occupation qualifies you as working in the Service Industry?*

    Please select the category that best describes your job. Only one parent is required to be working in the Service Industry.

  51. Please submit proof of employment in the qualifying occupation. Examples of acceptable documentation are:

    Current paystub (within last 30 days), employment verification form signed by employer, or signed letter of employment on company letterhead with company contact information.

  52. By signing this document, you agree to the following statements:*

    I certify that I qualify as a Service Industry Worker, require child care to work, my family income is at or below 75% SMI and the address I have provided is my current residential address. I also certify that I am meeting the participation requirements for my household size (25 hrs. per week for single parent/50 hrs. per week for two-parent household). 

    I understand that child care is only provided for 12 months and I will have to reapply for child care services at the end of the 12-month timeframe. Upon re-applying I may be subject to a waitlist and will not have child care services while on the waitlist or during the eligibility process.  

    I certify that all information provided on this form is accurate and child care may be terminated if any of this information is found to be inaccurate. I understand that giving false information may constitute fraud and could result in prosecution and/or repayment of money for services for which I was not entitled.

    By checking the "I agree" box above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  53. Documents required to be submitted prior to eligibility determination for SIR child care:

    - Proof of employment in a qualifying occupation. 

    - Proof of citizenship/legal immigration status for children needing care.

    - Completed and signed SIR Child Care Enrollment Form (this application).

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