CHILD CARE APPLICATION

1 South Carolina Department of Social ServicesSC Voucher ProgramCHILD care APPLICATIONSi necesita esta aplicaci n en idioma espa ol, llame al 1-800-476-0199 por COMPLETE IN BLUE OR BLACK INKAND COMPLETE ALLSECTIONSDSS Form 3791 (MAY 19) Edition of a APR 16 is nnNnnSingle Parent FamilynnTwo Parent FamilynnSingle Parent Guardian/In LocoParentisnnTwo Parent Guardian/In LocoParentisnnFoster CHILD of a Single ParentFamilynnFoster CHILD of a Two Parent FamilynnFoster CHILD with a ChildnnSinglennMarriednnSeparatednnDivor cednnWidowednnNot Applicable Child1. Tell us who you are and where you AGENCY USE ONLYP rogram Name/Eligibility Category:CCVS APPLICATION No.:Last Name:First Name:Residence Address:Social Security Number:Birthdate:County: (You live in)E-Mail:City:Mid.

2 Initial:State:SCZip:Mailing Address: (If different than residential address)CHIP Case No.: (If applicable)Has the family been homeless for one or more days during the month of this APPLICATION ? nnYes nnNoNOTE: Homeless is defined as individuals who lack a fixed, regular, and adequate nighttime Indianor Alaskan NativennY nnNBlack or AfricanAmericannnY nnNNative Hawaiianor Pacific IslandernnY nnNAsiannnY nnNWhitennY nnNHispanic/LatinoWhat is the primary language spoken in the home? nEnglishnSpanishnNative Central, South American LanguagesnMexican LanguagesnCaribbean LanguagesnMiddle Eastern or South Asian LanguagesnEast Asian LanguagesnNative North American/Alaska Native LanguagesnPacific Island LanguagesnEuropean or Slavic LanguagesnAfrican LanguagesnOther ( American Sign Language)nUnspecified*You must check Yes or No for each of the races and ethnicities listed.

3 Any option left unchecked will be recorded as * CheckYes or No for EachEthnicityCheckYes or NoLanguageFamily Composition(Select One)Marital Status(Select One)Educational Level(Select One)Home: ()-Work: ()-Cell: ()-City:State:SCZip:Gender:nnM nnFnnLess than HighSchool GraduatennHigh SchoolGraduatennGEDnnPost Graduate(College)DSS Form 3791 (MAY 19) Edition of a APR 16 is 22. Tell us about your NameFirst NameMiddleInitialGenderAgeHow is this personrelated to you?If CHILD age18-21, are theyin school?3. Tell us who lives in your home. (List your name on the first line.)Birthdate4. Tell us where you work or attend school or A Work/School/Training InformationName of Parent/Guardian/Foster Parent:Employment/School/Training Status: (Check all that apply)nnEmployednnEmployed/Attending School/TrainingnnAttending School/nnProtective ServicesTrainingnnDisablednnFederal Declared EmergencyEmployment/School/Training Status: (Check all that apply)nnEmployednnEmployed/Attending School/TrainingnnAttending School/nnProtective ServicesTrainingnnDisablednnFederal Declared EmergencyEmployer:School/Training ProgramAttending:Employer Address: (Includingcity, state, zip)School/Training Address:Contact Person at Work:Contact Person atSchool/Training:Contact Person s Phone No.

4 :( )Contact Person s Phone No.:( )How many hours do you workeach week?Active military status? nnNo nnYes, active duty US militarynnYes, National Guard/Military ReserveActive military status? nnNo nnYes, active duty US militarynnYes, National Guard/Military ReserveHow many hours do you attendschool/training each week?Parent B(Spouse or CHILD s Other Parent, if in same household)Work/School/Training InformationName of Parent/Guardian/Foster Parent:Employer:School/Training ProgramAttending:Employer Address: (Includingcity, state, zip)School/Training Address:Contact Person at Work:Contact Person atSchool/Training:Contact Person s Phone No.:( )Contact Person s Phone No.:( )How many hours do you workeach week?How many hours do you attendschool/training each week?

5 Does the family have assets that exceed $1,000,000? nnYes nnNoSources of Income (You mustcheck Yes or No for each source. Any option left unchecked will be recorded as a No.)EmploymentHousing Voucher orCash AssistanceTANF (FamilyIndependence)SSI or Other FederalCash BenefitsFood StampsAlimonySourceCheckYes or NoGrossAmountHow OftenReceived?WhoGets theMoney?nnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNOther: (Specify)nnY nnNChild SupportSocial SecurityUnemploymentWorker sCompensationDisability IncomeVeteran s PensionSourceCheckYes or NoGrossAmountHow OftenReceived?WhoGets theMoney?nnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNOther: (Specify)nnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnN5.

6 Tell us about the children who need CHILD care s First Name: CHILD s Last Name:American Indian orAlaskan NativeIs the CHILD citizen?If no, are theya legal alien?Black or AfricanAmericanNative Hawaiian orPacific IslanderWhiteAre thechild simmunizationsup to date?AsianRace* CheckYes or Nofor EachRaceStatusCheckYes or NoHealthCheckYes or NoEthnicityAnswerYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNDoes thechild have adisability?nnY nnNAre thechild simmunizationsup to date?nnY nnNDoes thechild have adisability?nnY nnNAre thechild simmunizationsup to date?nnY nnNDoes thechild have adisability?nnY nnNnnY nnNnnY nnNnnY nnNHispanic/LatinonnY nnNDoes the CHILD currently attend school?School District:Attends half day only?

7 CHILD care needed all year?Attends full day? CHILD care needed school year only? CHILD care needed for school breaks and summerbreaks only?Additional InformationCheckYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNSocial Security Number:Birthdate:Age: CHILD s First Name: CHILD s Last Name:American Indian orAlaskan NativeIs the CHILD citizen?If no, are theya legal alien?Black or AfricanAmericanNative Hawaiian orPacific IslanderWhiteAsianRaceRaceStatusCheckYes or NoHealthCheckYes or NoEthnicityAnswerYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNHispanic/LatinonnY nnNDoes the CHILD currently attend school?School District:Attends half day only? CHILD care needed all year?Attends full day? CHILD care needed school year only?

8 CHILD care needed for school breaks and summerbreaks only?Additional InformationCheckYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNSocial Security Number:Birthdate:Age: CHILD s First Name: CHILD s Last Name:American Indian orAlaskan NativeIs the CHILD citizen?If no, are theya legal alien?Black or AfricanAmericanNative Hawaiian orPacific IslanderWhiteAsianRaceRaceStatusCheckYes or NoHealthCheckYes or NoEthnicityAnswerYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNHispanic/LatinonnY nnNDoes the CHILD currently attend school?School District:Attends half day only? CHILD care needed all year?Attends full day? CHILD care needed school year only? CHILD care needed for school breaks and summerbreaks only?Additional InformationCheckYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNSocial Security Number:Birthdate:Age:Space to enter additional children is provided on the next page.

9 * CheckYes or Nofor Each* CheckYes or Nofor EachNote: Checking No under immunizations up-to-date does not automatically disqualify your CHILD .*You must check Yes or No for each of the races and ethnicities listed. Any option left unchecked will be recorded as unknown. DSS Form 3791 (MAY 19) Edition of a APR 16 is obsolete. PAGE 35. Tell us about the children who need CHILD care s First Name: CHILD s Last Name:American Indian orAlaskan NativeIs the CHILD citizen?If no, are theya legal alien?Black or AfricanAmericanNative Hawaiian orPacific IslanderWhiteAsianRaceRaceStatusCheckYes or NoHealthCheckYes or NoEthnicityAnswerYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNHispanic/LatinonnY nnNDoes the CHILD currently attend school?

10 School District:Attends half day only? CHILD care needed all year?Attends full day? CHILD care needed school year only? CHILD care needed for school breaks and summerbreaks only?Additional InformationCheckYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNSocial Security Number:Birthdate:Age: CHILD s First Name: CHILD s Last Name:American Indian orAlaskan NativeIs the CHILD citizen?If no, are theya legal alien?Black or AfricanAmericanNative Hawaiian orPacific IslanderWhiteAsianRaceRaceStatusCheckYes or NoHealthCheckYes or NoEthnicityAnswerYes or NonnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNnnY nnNHispanic/LatinonnY nnNDoes the CHILD currently attend school?School District:Attends half day only? CHILD care needed all year?