Mock – 211 Child Care Frontline Child Care Application

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*

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:

Parent/Guardian Race

Parent/Guardian Ethnicity

Optional

Mock – 211 Child Care Frontline Child Care Application

Mock Frontline CC Application

Frontline Parent/Guardian Information