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Frontline Parent/Guardian Information
Are you currently receiving benefits from the Care 4 Kids Program?
*
Yes
No
Why is temporary care needed at this time?
*
Please place a checkmark in the box next to all reason(s) that apply:
Child’s regular child care provider is temporarily closed
Child’s school is temporarily closed
Child’s regular child care provider has limited capacity and cannot care for my child
Child usually stays with friend/family who can no longer care for my child
Child’s regular child care provider has permanently closed
You will not qualify for this program since you are already on the CAre 4 Kids program.
Household Income
*
Is your gross household income below the amounts shown in the table above based on family size.
Yes
No
You will not qualify for this program since your income is above the threshold of what this program allows.
Name of Parent/Guardian
*
First
Middle
Last
Parent/Guardian Date of Birth
*
Date Format: MM slash DD slash YYYY
Parent/Guardian Gender
Male
Female
Other
Parent/Guardian Email
Parent/Guardian Home Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Parent/Guardian Cell Phone
Name and Address of your workplace
*
Work Phone
*
Occupation
*
Which occupation qualifies you as an essential worker during the COVID-19 pandemic? Please place a checkmark by the occupation category that best describes you below:
First Choice
Second Choice
Third Choice
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eee
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ggg
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Parent/Guardian Race
Black or African American
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
White
Asian
Parent/Guardian Ethnicity
Optional
Hispanic or Latinx
Not Hispanic or Latinx
×
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