This is an application for child care services. This application must be approved by Los Angeles County or the Child Care Agency and your provider must be determined eligible before any child care expenses can be paid. The County or the Child Care Agency will send you a notice informing you if your child care is approved or denied within 10 days of receipt of a completed application package. Do not use white out when completing this form. Please make a copy for your files.
A.CASE INFORMATION: Must be completed by the Participant or Child Care Agency. (Please Print)
1. |
Participant Name:_____________________________________ |
2. |
CalWORKs Case #: |
______________________________ |
3.Address (include city & zip code) __________________________________________________________
4.Daytime Phone #: (___) _______________________ Cell Phone #: (___)________________________
5. E-mail Address (optional): ____________________________ Text messages OK? |
Yes |
No |
B.CHILD CARE NEEDED: Must be completed by the Participant. Questions? Call __________________.
1.Please list the name and birth date of all your children up to age 12 (or under 18 if special needs that will require a case-by-case evaluation) who will be in child care with the provider listed on the back of this form.
You must fill out a separate form for each provider.
Child’s Name |
Date Of Birth |
Child’s Name |
Date Of Birth |
a)_________________________________________ b) _________________________________________
c)_________________________________________ d) _________________________________________
e)_________________________________________ f) __________________________________________
2.I need child care by date (mm/dd/yy): ___________________________.
3.I am asking for all the child care hours I am eligible for based on my approved activity and travel time._________
(Please initial)
C.PARTICIPANT DECLARATION: Please read carefully and sign below.
I understand that:
1.I have the right to choose the child care provider who I want. If I change providers, I must tell the County or the Child Care Agency immediately. If I don’t report the change, they won’t be paid.
2.I must notify the County or Child Care Agency within 5 calendar days of any changes to my income, family size, residence, employment or reason for needing child care services. If I do not, then it may affect my child care services.
3.If I choose an unlicensed child care provider, he/she must be Trustline-registered. This means he/she must pass a
criminal background check. The home where child care is provided must be a safe place to care for my child (Health and Safety Self-Certification criteria). We won’t pay until he/she meets these rules.
4.License-exempt centers, such as before or after school programs, YMCA, and/or my child’s aunt, uncle, or grandparent do not have to be Trustline-registered and are exempt from Health and Safety Self-Certification.
5.I must pay back any child care payments I am not entitled to receive.
6.The County or Child Care Agency is not my child care provider’s employer.
7.I may have to pay a family fee (a share of the cost of child care based on my income). The County or Child Care Agency will notify me if I must pay a family fee.
8.If the County or Child Care Agency cannot pay what my provider charges because it is over the limit, I will have to pay the difference (co-payment) to the provider. I can also change to a provider that charges less.
9.The CalWORKs Stage 1 Child Care Program does not pay for school tuition.
10.For families who do not have a set schedule for work and/or school, the County or Child Care Agency cannot pre- approve a set number of hours. The Child Care Agency will pay my provider at the end of the month based on my reported and verified hours. I will be responsible to pay for any child care hours over that amount.
11.Information on this form or about my eligibility may be shared with other County agencies, the State of California, the Federal Government, independent auditors, or others, as necessary for the administration of the program or to comply with State and Federal laws.
12.This application is subject to change, as needed, to comply with State or Federal regulations.
I acknowledge that I have read, understand, and agree to comply with the above terms. I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained on this page is true and correct to the best of my knowledge.
Participant’s Signature: ______________________________ Date: _______________________
ST1-05 (REV. 7/11) [CalWORKs Stage 1 Child Care Participant-Provider Services Application]
