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Child Care Assistance Application Form
Pre-Qualification
Personal Information
Children
Survey
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Pre-Qualification
Do you live in Dallas County, TX?
Please Choose
Yes
No
Are you are a single parent household, (currently working and/or in job training or an educational program for a minimum of 25 total combined hours a week or more)?
OR
Are you a teenage parent - 18 & younger, who needs child care so that you can graduate?
OR
Are you a two-parent household, (who are BOTH currently working and/or in job training or an educational program for a minimum of 50 total combined hours a week or more)?
Please Choose
Yes
No
Are you homeless?
Please Choose
Yes
No
How many people are in your family?
Please Select A Number
2
3
4
5
6
7
8
9
10
Do you earn
less
than
per month?
Including ALL income received on a monthly basis, before taxes have been taken out
Please Choose
Yes
No
Marital Status
Please Select Marital Status
Married
Separated
Divorced
Single
Are you currently employed?
Please Choose
Yes
No
Is your spouse currently employed?
Please Choose
Yes
No
Are you currently attending school?
Please Choose
Yes
No
Is your spouse currently attending school?
Please Choose
Yes
No
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