Application for Day Care Services Instructions
This form contains 122 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Applicant Information | ||
| Applicant Name | Text |
Please provide the applicant's full name, including last name and first name.
|
| Residence Address | Text |
Please enter the applicant's full residential street address.
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| Residence City | Text |
Please provide the city of the applicant's residence.
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| Residence State | Text |
Please enter the state of the applicant's residence.
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| Residence Zip Code | Text |
Please provide the zip code of the applicant's residence.
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| Mailing Address | Text |
If different from the residence, please provide the applicant's full mailing address.
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| Daytime Phone Number | Text |
Please provide the applicant's daytime phone number.
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| Cell Phone Number | Text |
Please provide the applicant's cell phone number.
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| Email Address | Text |
Please provide the applicant's email address.
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| Last Four Digits of SSN | Text |
Please enter the last four digits of the applicant's Social Security Number.
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| Application Type | ||
| Foster Care/Employment-related | Checkbox |
Check this box if the application type is Foster Care and is employment-related.
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| Foster Care/Family Maintenance | Checkbox |
Check this box if the application type is Foster Care and relates to family maintenance.
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| Subsidized Adoption/Legal Guardianship | Checkbox |
Check this box if the application type is for Subsidized Adoption or Legal Guardianship.
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| Teen Parent (school/employment-related) | Checkbox |
Check this box if the application type is for a Teen Parent whose situation is school or employment-related.
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| Protective/Intact Family Services/Teen Parent (not employment-related) | Checkbox |
Check this box if the application type is for Protective/Intact Family Services or for a Teen Parent whose situation is not employment-related.
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| Co-Applicant Employment Information | ||
| Co-Applicant Employer/Company Name | Text |
Please enter the full name of the co-applicant's employer or company, including the department if applicable. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-Applicant Employment Phone Number | Text |
Please enter the co-applicant's employer's phone number, including any extension. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-Applicant Employment Address | Text |
Please enter the full street address of the co-applicant's employer or office. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-Applicant Employment City | Text |
Please enter the city where the co-applicant's employer or office is located. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-Applicant Employment State | Text |
Please enter the state where the co-applicant's employer or office is located. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-Applicant Employment Zip Code | Text |
Please enter the zip code of the co-applicant's employer or office. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-Applicant Information | ||
| Co-applicant Name | Text |
Please provide the co-applicant's full name, with the last name followed by the first name.
|
| Co-applicant Daytime Phone Number | Text |
Please provide the co-applicant's daytime telephone number.
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| Co-applicant Cell Phone Number | Text |
Please provide the co-applicant's cell phone number.
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| Co-applicant Email Address | Text |
Please provide the co-applicant's email address.
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| Co-applicant SSN Last Four Digits | Text |
Please provide the last four digits of the co-applicant's Social Security Number.
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| Co-applicant School Schedule | ||
| Monday School Schedule | Text |
Enter the co-applicant's school schedule for Monday, including both start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Tuesday School Schedule | Text |
Enter the co-applicant's school schedule for Tuesday, including both start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Wednesday School Schedule | Text |
Enter the co-applicant's school schedule for Wednesday, including both start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Thursday School Schedule | Text |
Enter the co-applicant's school schedule for Thursday, including both start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Friday School Schedule | Text |
Enter the co-applicant's school schedule for Friday, including both start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Saturday School Schedule | Text |
Enter the co-applicant's school schedule for Saturday, including both start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Sunday School Schedule | Text |
Enter the co-applicant's school schedule for Sunday, including both start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-Applicant School/Training Information | ||
| School/Institution Name | Text |
Please enter the name of the school or training institution the co-applicant attends. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| School/Institution Phone Number | Text |
Please enter the phone number, including any extension, for the school or training institution. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| School/Institution Site Address | Text |
Please enter the street address of the school or training institution. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| School/Institution City | Text |
Please enter the city where the school or training institution is located. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| School/Institution State | Text |
Please enter the state where the school or training institution is located. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| School/Institution Zip Code | Text |
Please enter the zip code for the school or training institution's address. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Co-applicant Work Schedule | ||
| Monday Work Schedule | Text |
Enter the co-applicant's work schedule for Monday, including the start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Tuesday Work Schedule | Text |
Enter the co-applicant's work schedule for Tuesday, including the start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Wednesday Work Schedule | Text |
Enter the co-applicant's work schedule for Wednesday, including the start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Thursday Work Schedule | Text |
Enter the co-applicant's work schedule for Thursday, including the start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Friday Work Schedule | Text |
Enter the co-applicant's work schedule for Friday, including the start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Saturday Work Schedule | Text |
Enter the co-applicant's work schedule for Saturday, including the start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Sunday Work Schedule | Text |
Enter the co-applicant's work schedule for Sunday, including the start and end times. Fill only if 'Co-applicant Name' is filled
Depends on:
Co-applicant Name
|
| Current Day Care Service Arrangement | ||
| Monday Time | Time |
Enter the time for the current day care service arrangement on Monday.
|
| Tuesday Time | Time |
Enter the time for the current day care service arrangement on Tuesday.
|
| Wednesday Time | Time |
Enter the time for the current day care service arrangement on Wednesday.
|
| Thursday Time | Time |
Enter the time for the current day care service arrangement on Thursday.
|
| Friday Time | Time |
Enter the time for the current day care service arrangement on Friday.
|
| Saturday Time | Time |
Enter the time for the current day care service arrangement on Saturday.
|
| Sunday Time | Time |
Enter the time for the current day care service arrangement on Sunday.
|
| Day Care Family ID | ||
| Day Care Family ID | Number |
Enter the identification number assigned to the day care family.
|
| Day Care Provider Details | ||
| Facility/Provider's Name | Text |
The name of the day care facility or provider.
|
| Social Security Number | Text |
The Social Security Number of the day care provider.
|
| Street Address | Text |
The street address of the day care facility or provider.
|
| FEIN | Text |
The Federal Employer Identification Number (FEIN) of the day care provider.
|
| City, State, and Zip Code | Text |
The city, state, and zip code of the day care facility or provider's address.
|
| County | Text |
The county where the day care facility or provider is located.
|
| Telephone Number | Text |
The telephone number of the day care facility or provider.
|
| Email Address | Text |
The email address of the day care facility or provider.
|
| Employment Information | ||
| Employer/Company Name/Department | Text |
Please enter the name of your employer, company, or department.
|
| Employer Phone Number (ext) | Text |
Please provide the phone number of your employer, including any extension if applicable.
|
| Employment/Office Address | Text |
Please enter the street address of your employment or office.
|
| Employment City | Text |
Please enter the city where your employment or office is located.
|
| Employment State | Text |
Please enter the state where your employment or office is located.
|
| Employment Zip Code | Text |
Please enter the zip code of your employment or office.
|
| Employment Training Information | ||
| School/Institution Name | Text |
Enter the full name of the school or institution where you attend employment training. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Phone Number (Ext.) | Text |
Enter the phone number, including any extension, for the school or institution where you attend employment training. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Site Address | Text |
Enter the street address of the school or institution where you attend employment training. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| City | Text |
Enter the city of the school or institution where you attend employment training. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| State | Text |
Enter the state of the school or institution where you attend employment training. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Zip Code | Text |
Enter the zip code of the school or institution where you attend employment training. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| First Child Information | ||
| Child's Name | Text |
Enter the full name of the child, with the last name followed by the first name.
|
| Social Security Number | Text |
Enter the Social Security Number of the child.
|
| Date of Birth | Date |
Enter the child's date of birth.
|
| DCFS Case ID Number | Text |
Enter the DCFS Case ID Number for the child, if applicable.
|
| Relationship to Applicant | Text |
Enter the child's relationship to the applicant.
|
| Start Date | Date |
Enter the start date for day care services, if known.
|
| End Date | Date |
Enter the end date for day care services, if known or requested.
|
| Marital Status | ||
| Single | Checkbox |
Check this box if the applicant is currently single and has never been married, or if their previous marriage was annulled.
|
| Married | Checkbox |
Check this box if the applicant is currently legally married.
|
| Legal Civil Union | Checkbox |
Check this box if the applicant is currently in a legal civil union.
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| Legally Separated | Checkbox |
Check this box if the applicant is legally separated from their spouse but not yet divorced.
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| Legally Divorced | Checkbox |
Check this box if the applicant's marriage has been legally dissolved by divorce.
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| Widowed | Checkbox |
Check this box if the applicant's spouse has passed away and the applicant has not remarried.
|
| Provider's Date of Birth | ||
| Date of Birth Month | Date |
Please enter the month of the provider's date of birth. Fill only if 'Facility/Provider's Name' is an individual provider.
Depends on:
Facility/Provider's Name
|
| Date of Birth Day | Date |
Please enter the day of the provider's date of birth. Fill only if 'Facility/Provider's Name' is an individual provider.
Depends on:
Facility/Provider's Name
|
| Date of Birth Year | Date |
Please enter the year of the provider's date of birth. Fill only if 'Facility/Provider's Name' is an individual provider.
Depends on:
Facility/Provider's Name
|
| Provider's Mailing Address | ||
| Mailing Address Street | Text |
Enter the street address for the provider's mailing address, if it is different from the physical address.
|
| Mailing Address City | Text |
Enter the city for the provider's mailing address.
|
| Mailing Address State | Text |
Enter the state for the provider's mailing address.
|
| Mailing Address Zip Code | Text |
Enter the zip code for the provider's mailing address.
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| School Schedule (Second Row) | ||
| Monday School Schedule | Text |
Enter the applicant's school schedule for Monday, including start and end times. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Tuesday School Schedule | Text |
Enter the applicant's school schedule for Tuesday, including start and end times. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Wednesday School Schedule | Text |
Enter the applicant's school schedule for Wednesday, including start and end times. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Thursday School Schedule | Text |
Enter the applicant's school schedule for Thursday, including start and end times. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Friday School Schedule | Text |
Enter the applicant's school schedule for Friday, including start and end times. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Saturday School Schedule | Text |
Enter the applicant's school schedule for Saturday, including start and end times. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Sunday School Schedule | Text |
Enter the applicant's school schedule for Sunday, including start and end times. Fill only if 'Teen Parent (school/employment-related)', 'Protective/Intact Family Services/Teen Parent (not employment-related)' is 'Yes', any.
Depends on:
Teen Parent (school/employment-related), Protective/Intact Family Services/Teen Parent (not employment-related)
|
| Second Child Information | ||
| Child's Name (Last, First) | Text |
Enter the full name of the second child, including their last and first name.
|
| Social Security Number | Text |
Enter the Social Security Number for the second child.
|
| Date of Birth | Date |
Enter the date of birth for the second child.
|
| DCFS Case ID Number | Text |
Enter the DCFS (Department of Children and Family Services) Case ID number for the second child.
|
| Relationship to Applicant | Text |
Enter the second child's relationship to the applicant.
|
| Start Date | Date |
Enter the start date for day care services for the second child, if known.
|
| End Date | Date |
Enter the end date for day care services for the second child, if known or requested.
|
| Third Child Information | ||
| Third Child Name | Text |
Please enter the full name of the third child for whom day care services are being requested, including their last and first name.
|
| Third Child Social Security Number | Text |
Please enter the Social Security Number for the third child.
|
| Third Child Date of Birth | Date |
Please enter the date of birth for the third child.
|
| Third Child DCFS Case ID Number | Text |
Please enter the DCFS Case ID Number for the third child.
|
| Third Child Relationship to Applicant | Text |
Please enter the relationship of the third child to the applicant.
|
| Third Child Start Date | Date |
Please enter the start date for day care services for the third child, if known.
|
| Third Child End Date | Date |
Please enter the requested or known end date for day care services for the third child.
|
| Work Schedule (First Row) | ||
| Work Hours Monday | Text |
Enter the work hours for Monday, typically in a 'from - to' format (e.g., 9:00 AM - 5:00 PM).
|
| Work Hours Tuesday | Text |
Enter the work hours for Tuesday, typically in a 'from - to' format (e.g., 9:00 AM - 5:00 PM).
|
| Work Hours Wednesday | Text |
Enter the work hours for Wednesday, typically in a 'from - to' format (e.g., 9:00 AM - 5:00 PM).
|
| Work Hours Thursday | Text |
Enter the work hours for Thursday, typically in a 'from - to' format (e.g., 9:00 AM - 5:00 PM).
|
| Work Hours Friday | Text |
Enter the work hours for Friday, typically in a 'from - to' format (e.g., 9:00 AM - 5:00 PM).
|
| Work Hours Saturday | Text |
Enter the work hours for Saturday, typically in a 'from - to' format (e.g., 9:00 AM - 5:00 PM).
|
| Work Hours Sunday | Text |
Enter the work hours for Sunday, typically in a 'from - to' format (e.g., 9:00 AM - 5:00 PM).
|