Department of Children and Family Services (DCFS) Day Care Service Eligibility Application Instructions
This form contains 301 fields organized into 47 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| 1st Child Day Care Arrangements | ||
| Year round | Checkbox |
Check this box if the 1st child requires day care services throughout the entire year. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| School year only | Checkbox |
Check this box if the 1st child requires day care services only during the school year. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| School break only | Checkbox |
Check this box if the 1st child requires day care services only during school breaks. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Summer only | Checkbox |
Check this box if the 1st child requires day care services only during the summer. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Other (explain) | Checkbox |
Check this box if the 1st child's day care arrangement does not fit the other listed options and requires explanation. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Other Care Arrangement Explanation | Text |
Explain the specific care arrangement if none of the provided options (Year round, School year only, School break only, Summer only) apply for the first child. Fill only if 'Other (explain)' is 'Yes'.
Depends on:
Other (explain)
|
| Child's Name | Text |
Enter the full name of the first child for whom day care services are being requested, including their last and first name. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Number of Days Per Week | Text |
Enter the number of days per week the first child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Number of Hours Per Day | Number |
Enter the number of hours per day the first child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Daily Care Start Time | Time |
Enter the daily start time for the first child's care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| FROM am | Checkbox |
Check this box if the 1st child's daily care begins in the morning. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| FROM pm | Checkbox |
Check this box if the 1st child's daily care begins in the afternoon or evening. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Daily Care End Time | Time |
Enter the daily end time for the first child's care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| TO am | Checkbox |
Check this box if the 1st child's daily care ends in the morning. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| TO pm | Checkbox |
Check this box if the 1st child's daily care ends in the afternoon or evening. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Daily Care Charge | Number |
Enter the daily amount the day care provider charges for the first child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 2nd Child Day Care Arrangements | ||
| Second Child's Full Name | Text |
Please provide the full name of the second child (Last, First). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child's Care Days Per Week | Number |
Please enter the number of days per week the second child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child's Care Hours Per Day | Number |
Please enter the number of hours per day the second child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child Daily Care Start Time | Time |
Please specify the start time for the second child's daily care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 2nd Child FROM am | Checkbox |
Check this box if the 2nd child's day care for the 'FROM' time is in the morning (am). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 2nd Child FROM pm | Checkbox |
Check this box if the 2nd child's day care for the 'FROM' time is in the afternoon or evening (pm). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child Daily Care End Time | Time |
Please specify the end time for the second child's daily care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 2nd Child TO am | Checkbox |
Check this box if the 2nd child's day care for the 'TO' time is in the morning (am). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 2nd Child TO pm | Checkbox |
Check this box if the 2nd child's day care for the 'TO' time is in the afternoon or evening (pm). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child Daily Care Charge | Number |
Please enter the daily charge by the day care provider for the second child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child Day Care Arrangements | ||
| 3rd Child's Name | Text |
Please enter the full name of the third child, last name first. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child Days of Care per Week | Text |
Please enter the number of days the third child will receive care per week. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child Hours of Care per Day | Text |
Please enter the number of hours the third child will receive care per day. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child Daily Care From Time | Time |
Please enter the time the third child's daily care begins. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child From AM | Checkbox |
Check this box if the 3rd child's day care service starts in the AM. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child From PM | Checkbox |
Check this box if the 3rd child's day care service starts in the PM. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child Daily Care To Time | Time |
Please enter the time the third child's daily care ends. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child To AM | Checkbox |
Check this box if the 3rd child's day care service ends in the AM. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child To PM | Checkbox |
Check this box if the 3rd child's day care service ends in the PM. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 3rd Child Daily Care Charge | Number |
Please enter the daily charge for the third child's day care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 4th Child Day Care Arrangements | ||
| Year round | Checkbox |
Check this box if the child will be cared for year-round. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| School year only | Checkbox |
Check this box if the child will be cared for only during the school year. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| School break only | Checkbox |
Check this box if the child will be cared for only during school breaks. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Summer only | Checkbox |
Check this box if the child will be cared for only during the summer. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Other (explain) | Checkbox |
Check this box if the child's care arrangement does not fit the other options and requires an explanation. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 4th Child Other Care Arrangement Explanation | Text |
Provide an explanation if 'Other' is selected for the 4th child's day care arrangement type. Fill only if 'Other (explain)' is 'Yes'.
Depends on:
Other (explain)
|
| 4th Child Name | Text |
Enter the full name (Last, First) of the 4th child for whom day care services are being arranged. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 4th Child Days of Care Per Week | Text |
Enter the number of days per week the 4th child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 4th Child Hours of Care Per Day | Text |
Enter the number of hours per day the 4th child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 4th Child Daily Care From Time | Time |
Enter the starting time of day the 4th child will be cared for. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| From AM | Checkbox |
Check this box if the 'FROM' time for daily care is in the morning (am). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| From PM | Checkbox |
Check this box if the 'FROM' time for daily care is in the afternoon or evening (pm). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 4th Child Daily Care To Time | Time |
Enter the ending time of day the 4th child will be cared for. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| To AM | Checkbox |
Check this box if the 'TO' time for daily care is in the morning (am). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| To PM | Checkbox |
Check this box if the 'TO' time for daily care is in the afternoon or evening (pm). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 4th Child Daily Care Provider Charge | Number |
Enter the daily amount charged by the day care provider for the 4th child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 5th Child Day Care Arrangements | ||
| 5th Child Name | Text |
Enter the last name and first name of the 5th child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 5th Child Days of Care Per Week | Text |
Enter the number of days per week the 5th child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 5th Child Hours of Care Per Day | Number |
Enter the number of hours per day the 5th child will receive care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 5th Child Care Start Time | Time |
Enter the time the 5th child's care arrangement starts each day. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| FROM am | Checkbox |
Check this box if the start time for the 5th child's daily care is in the morning (ante meridiem). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| FROM pm | Checkbox |
Check this box if the start time for the 5th child's daily care is in the afternoon or evening (post meridiem). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 5th Child Care End Time | Time |
Enter the time the 5th child's care arrangement ends each day. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| TO am | Checkbox |
Check this box if the end time for the 5th child's daily care is in the morning (ante meridiem). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| TO pm | Checkbox |
Check this box if the end time for the 5th child's daily care is in the afternoon or evening (post meridiem). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 5th Child Daily Care Charge | Number |
Enter the daily amount the day care provider charges for the 5th child's care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child Day Care Arrangements | ||
| 6th Child Name | Text |
Provide the last and first name of the 6th child for whom day care services are being arranged. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child Days of Care per Week | Text |
Enter the total number of days per week the 6th child will be in care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child Hours of Care per Day | Text |
Enter the total number of hours per day the 6th child will be in care. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child Care Start Time | Time |
Enter the time of day when the 6th child's care arrangement will begin. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child From AM | Checkbox |
Check this box if the 6th child's daily care is scheduled to begin in the morning (AM). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child From PM | Checkbox |
Check this box if the 6th child's daily care is scheduled to begin in the afternoon or evening (PM). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child Care End Time | Time |
Enter the time of day when the 6th child's care arrangement will end. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child To AM | Checkbox |
Check this box if the 6th child's daily care is scheduled to end in the morning (AM). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child To PM | Checkbox |
Check this box if the 6th child's daily care is scheduled to end in the afternoon or evening (PM). Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| 6th Child Daily Care Charge | Number |
Enter the amount the day care provider will charge daily for the 6th child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Applicant Certifications | ||
| Child current on immunizations | Checkbox |
Check this box if the child(ren) is(are) current on all immunizations and verification is on file with the Day Care Provider (if applicable- licensed center, home or license-exempt facility).
|
| Facility review completed and safe environment | Checkbox |
Check this box if a review of the facility/home has been completed and you agree that it is a safe environment.
|
| Written notification for pick-up authorization | Checkbox |
Check this box if written notification has been given to the Day Care Provider listing anyone, other than yourself, authorized to pick up the child(ren).
|
| Emergency phone and medical consent given | Checkbox |
Check this box if an emergency phone number, written consent for medical care, and consent for dispensing prescription medication have been given to the Day Care Provider.
|
| Physician info on file | Checkbox |
Check this box if the name and telephone number of the child's or family physician is on file with the Day Care Provider.
|
| Information provided is true, complete, and correct | Checkbox |
Check this box if all information provided on this document is true, complete, and correct.
|
| Responsible for service provided | Checkbox |
Check this box if you are responsible for the service provided to the child(ren).
|
| Notify Department of changes | Checkbox |
Check this box if you agree to notify the Department's Regional Day Care Service Unit of any change in Day Care arrangements.
|
| General Certification of Truthfulness and Understanding | Checkbox |
Check this box to certify that the information provided is true, accurate, and complete, and that you understand the terms regarding disclosure, verification, consequences of falsification, and your right to appeal.
|
| Certification | ||
| Worker's Printed Name | Text |
Enter the printed full name of the DCFS/POS worker.
|
| Supervisor's Printed Name | Text |
Enter the printed full name of the DCFS/POS supervisor.
|
| Co-applicant's Information | ||
| Co-applicant Name | Text |
Enter the co-applicant's full name, with the last name followed by the first name.
|
| Co-applicant Daytime Phone Number | Text |
Enter the co-applicant's daytime phone number.
|
| Co-applicant Cell Phone Number | Text |
Enter the co-applicant's cell phone number.
|
| Co-applicant Email Address | Text |
Enter the co-applicant's email address.
|
| Co-applicant SSN (Last Four Digits) | Text |
Enter the last four digits of the co-applicant's Social Security Number.
|
| Date of Birth | ||
| Date of Birth Month | Text |
Please provide the month of birth. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Date of Birth Day | Text |
Please provide the day of birth. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Date of Birth Year | Text |
Please provide the year of birth. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Day Care Service Provider Certifications | ||
| Unrestricted Access to Children | Checkbox |
Check this box if the applicant, parents, foster parents, relative caregivers, adoptive parents, guardians, or teen parents will have unrestricted access to their children at all times, unless a court order prohibits contact. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Corporal Punishment Prohibited | Checkbox |
Check this box to certify that corporal punishment, spanking, or harsh treatment of any kind is prohibited for children in care. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Compliance with Safety Codes | Checkbox |
Check this box to certify that all state and local fire, health, and safety codes have been followed. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Functioning Smoke Detectors | Checkbox |
Check this box to certify that smoke detectors are functioning properly and are placed in the recommended safety areas of the residence/facility. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Functioning Carbon Monoxide Detectors | Checkbox |
Check this box to certify that carbon monoxide detectors are functioning properly and are placed in the recommended safety areas of the residence/facility. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Current TB Test and Physical Examination | Checkbox |
Check this box to certify that a current TB skin test and physical examination will be documented and on file within 90 days of signing this form. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Children Supervised at All Times | Checkbox |
Check this box to certify that children will be supervised at all times, including indoors, outdoors, near standing water, and in vehicles. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Firearms and Ammunition Stored Securely | Checkbox |
Check this box to certify that if firearms and ammunition are allowed in the State of Illinois, they are stored in a locked cabinet or locked storage at all times. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Hazardous Materials Inaccessible to Children | Checkbox |
Check this box to certify that all cleaning agents, poisons, and other hazardous materials are stored in an area inaccessible to children. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| First Aid Supplies Available | Checkbox |
Check this box to certify that first aid supplies are readily available. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Developmentally Appropriate Play Activities | Checkbox |
Check this box to certify that children will be provided with developmentally appropriate play activities. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Nutritious Meals and Snacks | Checkbox |
Check this box to certify that children will be given nutritious meals and snacks. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Compliance with All Laws and Regulations | Checkbox |
Check this box to certify that all services will be performed in accordance with all local, state, and federal laws, regulations, and standards. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| DCFS Rates Do Not Exceed Public Rates | Checkbox |
Check this box to certify that rates charged to the State of Illinois-DCFS do not exceed those charged to the general public for similar services. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Payment Based on Public Rates up to DCFS Max | Checkbox |
Check this box to certify that you will be paid what you charge the general public, up to the DCFS maximum rate schedule. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| No Collection from DCFS Parents | Checkbox |
Check this box to certify that you may not collect the DCFS day care rate, or any portion thereof, from the DCFS parent or foster parent. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Day Care Payments are Taxable Income | Checkbox |
Check this box to acknowledge that day care payments are considered income and will be reported as taxable income on U.S.IRS form 1099 Misc. by the State of Illinois. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Confidentiality of Client Information | Checkbox |
Check this box to certify that you will not release information concerning persons served by the Department without prior written approval, unless required by law. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Confidentiality Obligations for Staff and Subcontractors | Checkbox |
Check this box to certify that the Day Care Provider will inform all staff and subcontractors of confidentiality obligations and assure their compliance. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| W-9 Form Attached/On File | Checkbox |
Check this box to certify that a current, signed W-9 form is attached or already on file with the regional day care office. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| No History of Abuse or Exploitation | Checkbox |
Check this box to certify that you have not been a perpetrator of child abuse or neglect in the past five years, or sexual molestation/exploitation in the past twenty years, as specified. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| Authorization for Background Checks | Checkbox |
Check this box to authorize the Department to perform background checks using CANTS, SOR, and FBI databases. Fill only if 'DAY CARE TYPE' is unlicensed or license-exempt
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING, Non-Relative Care in Provider's Home, RELATIVE - Care provided in the home of a relative, RELATIVE - Care provided in the home of the child by a relative, Non-Relative Care in Child's Home
|
| DCFS/POS Agency Office Information | ||
| Worker Name | Text |
Please provide the full name of the caseworker or worker associated with the agency.
|
| Worker ID Number | Text |
Please enter the identification number assigned to the caseworker or worker.
|
| Agency Name | Text |
Please provide the full legal name of the DCFS/POS agency.
|
| Street Address | Text |
Please enter the street address of the agency.
|
| City | Text |
Please enter the city where the agency is located.
|
| State | Text |
Please enter the state where the agency is located, typically a two-letter abbreviation.
|
| Zip Code | Text |
Please enter the five-digit or nine-digit ZIP code for the agency's address.
|
| Telephone Number and Extension | Text |
Please provide the agency's telephone number, including any extension if applicable.
|
| Fax Number | Text |
Please provide the agency's fax number.
|
| Email Address | Text |
Please enter the primary email address for the agency.
|
| Employment Information | ||
| Text43 | Text | |
| Text44 | Text | |
| Text45 | Text | |
| Text46 | Text | |
| Text47 | Text | |
| Text48 | Text | |
| Employer Company Name | Text |
Enter the name of the employer, company, or department where the co-applicant is employed. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Employer Phone Number | Text |
Enter the phone number of the co-applicant's employer, including any extension. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Employer Address | Text |
Enter the complete employment or office address of the co-applicant's employer. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Employer City | Text |
Enter the city of the co-applicant's employer. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Employer State | Text |
Enter the state of the co-applicant's employer. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Employer Zip Code | Text |
Enter the zip code of the co-applicant's employer. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Employment Training Information | ||
| School/Institution Name | Text |
Enter the full name of the school or institution where the co-applicant attends employment training or a GED program. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Phone Number (Ext) | Text |
Enter the phone number, including any extension, for the school or institution. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Site Address | Text |
Enter the physical street address of the school or institution. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| City | Text |
Enter the city where the school or institution is located. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| State | Text |
Enter the state where the school or institution is located. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Zip Code | Text |
Enter the zip code for the school or institution's address. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Employment/School/Training Schedule Variation | ||
| My employment/school/training schedule varies | Checkbox |
Check this box if your employment, school, or training schedule changes or is not consistent, requiring further explanation on a separate sheet.
|
| Exempt Day Care Center Information | ||
| DAY CARE CENTER EXEMPT FROM LICENSING | Checkbox |
Check this box if your day care center is exempt from licensing requirements and you have a verification letter from the DCFS Licensing office. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Exempt Day Care Provider ID | Text |
Please enter the Provider ID number for the exempt day care center, if known. Fill only if 'DAY CARE CENTER EXEMPT FROM LICENSING' is 'Yes'.
Depends on:
DAY CARE CENTER EXEMPT FROM LICENSING
|
| Fifth Child Information Row | ||
| Fifth Child's Name (Last, First) | Text |
Provide the full name of the fifth child, with the last name followed by the first name. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fifth Child's Social Security Number | Text |
Provide the social security number for the fifth child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fifth Child's Date of Birth | Date |
Provide the date of birth for the fifth child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fifth Child's DCFS Case ID Number | Text |
Provide the DCFS case identification number for the fifth child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fifth Child's Relationship to Applicant | Text |
Provide the relationship of the fifth child to the applicant. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fifth Child's Start Date (if known) | Date |
Provide the start date for day care services for the fifth child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fifth Child's End Date (if known) | Date |
Provide the end date for day care services for the fifth child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| First Child Information Row | ||
| Child's Name | Text |
Provide the child's full name, with the last name first, followed by the first name. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Social Security Number | Text |
Enter the child's Social Security Number. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Date of Birth | Date |
Provide the child's date of birth. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| DCFS Case ID Number | Text |
Enter the DCFS Case ID Number for the child, if applicable. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Relationship to Applicant | Text |
State the child's relationship to the applicant. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Start Date | Date |
Provide the start date for day care services, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| End Date | Date |
Provide the end date for day care services, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| First Work Schedule | ||
| Monday Work Schedule | Text |
Enter the co-applicant's work schedule for Monday, specifying the start and end times (e.g., '9:00 AM - 5:00 PM'). Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Tuesday Work Schedule | Text |
Enter the co-applicant's work schedule for Tuesday, specifying the start and end times (e.g., '9:00 AM - 5:00 PM'). Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Wednesday Work Schedule | Text |
Enter the co-applicant's work schedule for Wednesday, specifying the start and end times (e.g., '9:00 AM - 5:00 PM'). Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Thursday Work Schedule | Text |
Enter the co-applicant's work schedule for Thursday, specifying the start and end times (e.g., '9:00 AM - 5:00 PM'). Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Friday Work Schedule | Text |
Enter the co-applicant's work schedule for Friday, specifying the start and end times (e.g., '9:00 AM - 5:00 PM'). Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Saturday Work Schedule | Text |
Enter the co-applicant's work schedule for Saturday, specifying the start and end times (e.g., '9:00 AM - 5:00 PM'). Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Sunday Work Schedule | Text |
Enter the co-applicant's work schedule for Sunday, specifying the start and end times (e.g., '9:00 AM - 5:00 PM'). Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Fourth Child Information Row | ||
| Fourth Child's Name | Text |
Enter the full name of the fourth child, including last name first, then first name. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fourth Child's Social Security Number | Text |
Enter the Social Security Number of the fourth child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fourth Child's Date of Birth | Date |
Enter the fourth child's date of birth. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fourth Child's DCFS Case ID Number | Text |
Enter the DCFS Case ID Number for the fourth child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fourth Child's Relationship to Applicant | Text |
Enter the fourth child's relationship to the applicant. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fourth Child's Start Date | Date |
Enter the start date for the fourth child's day care services, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Fourth Child's End Date | Date |
Enter the end date for the fourth child's day care services, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Licensed Day Care Center Information | ||
| LICENSED DAY CARE CENTER | Checkbox |
Check this box if the day care service provider is a licensed day care center. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| DCFS DCC License Number | Text |
Please provide the DCFS Day Care Center license number. Fill only if 'LICENSED DAY CARE CENTER' is 'Yes'.
Depends on:
LICENSED DAY CARE CENTER
|
| DCFS DCC License Expiration Date | Date |
Please provide the expiration date of the DCFS Day Care Center license. Fill only if 'LICENSED DAY CARE CENTER' is 'Yes'.
Depends on:
LICENSED DAY CARE CENTER
|
| Licensed Day Care Home Information | ||
| LICENSED DAY CARE HOME | Checkbox |
Check this box if the facility is a licensed day care home that cares for no more than 12 unrelated children under the age of 12, including the provider's own children. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| DCFS DCH License Number | Text |
Enter the DCFS Day Care Home license number. Fill only if 'LICENSED DAY CARE HOME' is 'Yes'.
Depends on:
LICENSED DAY CARE HOME
|
| License Expiration Date | Date |
Enter the expiration date of the DCFS Day Care Home license. Fill only if 'LICENSED DAY CARE HOME' is 'Yes'.
Depends on:
LICENSED DAY CARE HOME
|
| Licensed Group Day Care Home Information | ||
| Licensed Group Day Care Home | Checkbox |
Check this box if the day care is a licensed group day care home, caring for no more than 16 unrelated children under 12, including the provider's own children. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| DCFS GDCH License Number | Text |
Please provide the DCFS Group Day Care Home License number. Fill only if 'Licensed Group Day Care Home' is 'Yes'.
Depends on:
Licensed Group Day Care Home
|
| License Expiration Date | Date |
Please enter the expiration date of the DCFS Group Day Care Home License. Fill only if 'Licensed Group Day Care Home' is 'Yes'.
Depends on:
Licensed Group Day Care Home
|
| Mailing Address | ||
| Mailing Street Address | Text |
Please enter the street address for the mailing address. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Mailing City | Text |
Please enter the city for the mailing address. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Mailing State | Text |
Please enter the state for the mailing address. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Mailing Zip Code | Text |
Please enter the zip code for the mailing address. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Marital Status | ||
| Single | Checkbox |
Check this box if the primary applicant is currently single and has never been married, or if they are widowed, divorced, or legally separated but prefer to identify as single.
|
| Married | Checkbox |
Check this box if the primary applicant is currently legally married.
|
| Legal Civil Union | Checkbox |
Check this box if the primary applicant is currently in a legal civil union.
|
| Legally Separated | Checkbox |
Check this box if the primary applicant is legally separated from their spouse but not yet divorced.
|
| Legally Divorced | Checkbox |
Check this box if the primary applicant is legally divorced and their marriage has been dissolved.
|
| Widowed | Checkbox |
Check this box if the primary applicant's spouse has passed away and they have not remarried.
|
| Primary Applicant Information | ||
| Primary Applicant's Name | Text |
Please provide the full name of the primary applicant.
|
| Family ID Number | Text |
Please enter the Family ID number assigned by the Day Care office.
|
| DCFS Region | Text |
Please specify the DCFS region related to this application.
|
| Primary Applicant's Information | ||
| Primary Applicant Name | Text |
Please enter the primary applicant's full name, including last name and first name.
|
| Residence Address | Text |
Please enter the primary applicant's full residential street address.
|
| Residence City | Text |
Please enter the city of the primary applicant's residence.
|
| Residence State | Text |
Please enter the state of the primary applicant's residence.
|
| Residence Zip Code | Text |
Please enter the zip code of the primary applicant's residence.
|
| Mailing Address | Text |
Please enter the primary applicant's mailing address, if it is different from the residence address.
|
| Daytime Phone Number | Text |
Please enter the primary applicant's daytime phone number.
|
| Cell Phone Number | Text |
Please enter the primary applicant's cell phone number.
|
| Email Address | Text |
Please enter the primary applicant's email address.
|
| SSN Last Four Digits | Text |
Please enter the last four digits of the primary applicant's Social Security Number.
|
| Provider Contact Information | ||
| Telephone Number | Text |
Please provide the primary telephone number for the provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Fax Number | Text |
Please provide the fax number for the provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Email Address | Text |
Please provide the email address for the provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Provider Identification | ||
| Facility/Provider Name | Text |
Please provide the full name of the facility or provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Social Security Number | Text |
Please enter the Social Security Number of the provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| FEIN | Text |
Please enter the Federal Employer Identification Number. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Provider Street Address | ||
| Street Address | Text |
Enter the street address of the day care service provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| City, State, Zip | Text |
Enter the city, state, and zip code of the day care service provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| County | Text |
Enter the county where the day care service provider is located. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| Reason for Application | ||
| Initial Day Care Service Eligibility application | Checkbox |
Check this box if you are submitting an initial application for Day Care Service Eligibility.
|
| Parent/caregiver address change | Checkbox |
Check this box if there has been a change in the parent's or caregiver's address.
|
| Change of Day Care Provider | Checkbox |
Check this box if you are changing your current Day Care Provider.
|
| Request for secondary provider | Checkbox |
Check this box if you are requesting a secondary provider and have the necessary written justification from the caseworker.
|
| Add child(ren) to existing Day Care Service application | Checkbox |
Check this box if you need to add one or more children to an already existing Day Care Service application.
|
| Related/Unlicensed Provider Background Check | ||
| SACWIS System Background Check Required | Checkbox |
Check this box to indicate that a SACWIS system background check (CANTS and SOR) is required for related/unlicensed day care providers. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| SACWIS-based CANTS/SOR Checks Completed | Checkbox |
Check this box once the worker or supervisor has documented the date when the SACWIS-based CANTS/SOR checks were completed on the CFS 2000 - Part III/Section (B). Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
|
| SACWIS Background Check Results | Text |
Provide the results or status of the SACWIS-based background check for the related/unlicensed day care provider. Fill only if 'SACWIS System Background Check Required' is 'Yes'.
Depends on:
SACWIS System Background Check Required
|
| Schedule Variation | ||
| My employment/school/training schedule varies | Checkbox |
Check this box if your employment, school, or training schedule is not consistent or varies over time. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School Schedule | ||
| Monday School Schedule | Text |
Enter the time range, from start to end, that the applicant attends school on Monday.
|
| Tuesday School Schedule | Text |
Enter the time range, from start to end, that the applicant attends school on Tuesday.
|
| Wednesday School Schedule | Text |
Enter the time range, from start to end, that the applicant attends school on Wednesday.
|
| Thursday School Schedule | Text |
Enter the time range, from start to end, that the applicant attends school on Thursday.
|
| Friday School Schedule | Text |
Enter the time range, from start to end, that the applicant attends school on Friday.
|
| Saturday School Schedule | Text |
Enter the time range, from start to end, that the applicant attends school on Saturday.
|
| Sunday School Schedule | Text |
Enter the time range, from start to end, that the applicant attends school on Sunday.
|
| School Schedule Monday | Text |
Enter the time range for school on Monday. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School Schedule Tuesday | Text |
Enter the time range for school on Tuesday. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School Schedule Wednesday | Text |
Enter the time range for school on Wednesday. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School Schedule Thursday | Text |
Enter the time range for school on Thursday. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School Schedule Friday | Text |
Enter the time range for school on Friday. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School Schedule Saturday | Text |
Enter the time range for school on Saturday. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School Schedule Sunday | Text |
Enter the time range for school on Sunday. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| School/Training Information | ||
| School Institution Name | Text |
Please provide the full name of the school or training institution.
|
| School Phone Number | Text |
Please provide the phone number, including any extension, for the school or training institution.
|
| School Site Address | Text |
Please provide the street address of the school or training institution.
|
| School City | Text |
Please provide the city where the school or training institution is located.
|
| School State | Text |
Please provide the state where the school or training institution is located.
|
| School Zip Code | Text |
Please provide the zip code for the school or training institution's address.
|
| Second Child Information Row | ||
| Second Child Name | Text |
Enter the full name of the second child, including both last and first names. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child Social Security Number | Text |
Enter the Social Security Number of the second child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child Date of Birth | Date |
Enter the date of birth of the second child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child DCFS Case ID Number | Text |
Enter the DCFS Case ID Number associated with the second child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child Relationship to Applicant | Text |
Enter the relationship of the second child to the applicant. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child Start Date | Date |
Enter the start date for services for the second child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Child End Date | Date |
Enter the end date for services for the second child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Second Work Schedule | ||
| Second Work Monday Schedule | Text |
Enter the co-applicant's second work schedule for Monday, including start and end times. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Second Work Tuesday Schedule | Text |
Enter the co-applicant's second work schedule for Tuesday, including start and end times. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Second Work Wednesday Schedule | Text |
Enter the co-applicant's second work schedule for Wednesday, including start and end times. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Second Work Thursday Schedule | Text |
Enter the co-applicant's second work schedule for Thursday, including start and end times. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Second Work Friday Schedule | Text |
Enter the co-applicant's second work schedule for Friday, including start and end times. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Second Work Saturday Schedule | Text |
Enter the co-applicant's second work schedule for Saturday, including start and end times. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Second Work Sunday Schedule | Text |
Enter the co-applicant's second work schedule for Sunday, including start and end times. Fill only if 'Co-applicant Name (Last, First)' is filled
Depends on:
Co-applicant Name
|
| Sixth Child Information Row | ||
| Sixth Child's Full Name | Text |
Provide the full name of the sixth child requesting day care services, including last and first name. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Sixth Child's Social Security Number | Text |
Provide the Social Security Number for the sixth child requesting day care services. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Sixth Child's Date of Birth | Date |
Provide the date of birth for the sixth child requesting day care services. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Sixth Child's DCFS Case ID Number | Text |
Provide the DCFS Case ID Number for the sixth child requesting day care services. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Sixth Child's Relationship to Applicant | Text |
Provide the relationship of the sixth child to the applicant. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
|
| Sixth Child's Start Date | Date |
Provide the start date for day care services for the sixth child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Sixth Child's End Date | Date |
Provide the end date for day care services for the sixth child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Third Child Information Row | ||
| Third Child's Name | Text |
Provide the full name of the third child for whom day care services are being requested, in the format of Last Name, First Name. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Third Child's Social Security Number | Text |
Provide the Social Security Number of the third child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Third Child's Date of Birth | Date |
Provide the date of birth for the third child. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Third Child's DCFS Case ID Number | Text |
Provide the DCFS (Department of Children and Family Services) Case ID Number for the third child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Third Child's Relationship to Applicant | Text |
Provide the relationship of the third child to the applicant. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Third Child's Start Date | Date |
Provide the start date for day care services for the third child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Third Child's End Date | Date |
Provide the end date for day care services for the third child, if known. Fill only if 'Initial Day Care Service Eligibility application' is 'Yes'.
Depends on:
Initial Day Care Service Eligibility application
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| Type of Day Care Requested | ||
| Foster Parent Employment-related Day Care | Checkbox |
Check this box if day care is requested for a foster parent due to their employment.
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| Teen Parent Education or Employment-related Day Care | Checkbox |
Check this box if day care is requested for a teen parent due to their participation in school, employment, or skills training.
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| Protective/Family Maintenance Day Care | Checkbox |
Check this box if day care is requested for protective services or family maintenance purposes.
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| Open intact family | Checkbox |
Check this box if day care is requested for a child in an open intact family case. Fill only if 'Protective/Family Maintenance Day Care' is 'Yes'.
Depends on:
Protective/Family Maintenance Day Care
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| Family Reunification | Checkbox |
Check this box if day care is requested to support family reunification efforts. Fill only if 'Protective/Family Maintenance Day Care' is 'Yes'.
Depends on:
Protective/Family Maintenance Day Care
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| Foster Care | Checkbox |
Check this box if day care is requested for a child in foster care. Fill only if 'Protective/Family Maintenance Day Care' is 'Yes'.
Depends on:
Protective/Family Maintenance Day Care
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| Subsidized Adoptive Parent/Guardian - Employment-related Day Care | Checkbox |
Check this box if day care is requested for a child with a subsidized adoptive parent or guardian due to their employment.
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| Therapeutic Day Care (Foster Care) | Checkbox |
Check this box if therapeutic day care is requested for a child in foster care.
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| Unlicensed Day Care Home Network Contract | ||
| DAY CARE HOME NETWORK | Checkbox |
Check this box if your day care home operates as a network that contracts with licensed day care home providers. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
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| Provider ID | Text |
Enter the Provider ID for the Day Care Home Network, which contracts with licensed day care home providers. Fill only if 'DAY CARE HOME NETWORK' is 'Yes'.
Depends on:
DAY CARE HOME NETWORK
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| Unlicensed Non-Relative Care in Child's Home | ||
| Non-Relative Care in Child's Home | Checkbox |
Check this box if you are providing unlicensed care for a non-relative in the child's home. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
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| Provider ID (Non-Relative, Child's Home) | Text |
Enter the Provider ID for non-relative care provided in the child's home. Fill only if 'Non-Relative Care in Child's Home' is 'Yes'.
Depends on:
Non-Relative Care in Child's Home
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| Unlicensed Non-Relative Care in Provider's Home | ||
| Non-Relative Care in Provider's Home | Checkbox |
Check this box if non-relative care is provided in the home of the provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
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| Non-Relative Care Provider ID | Text |
Please provide the Provider ID for non-relative care provided in the provider's home. Fill only if 'Non-Relative Care in Provider's Home' is 'Yes'.
Depends on:
Non-Relative Care in Provider's Home
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| Unlicensed Relative Care in Child's Home | ||
| RELATIVE - Care provided in the home of the child by a relative | Checkbox |
Check this box if care is provided by a relative in the child's home. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
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| Relative Care In Child's Home Provider ID | Text |
Provide the identification number for the relative providing care within the child's own home under an unlicensed arrangement. Fill only if 'RELATIVE - Care provided in the home of the child by a relative' is 'Yes'.
Depends on:
RELATIVE - Care provided in the home of the child by a relative
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| Unlicensed Relative Care in Relative's Home | ||
| RELATIVE - Care provided in the home of a relative | Checkbox |
Check this box if the day care is provided by a relative in their own home to a child to whom they are related. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
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| Provider ID (Relative's Home) | Text |
Please provide the identification number for the provider of unlicensed relative care within a relative's home. Fill only if 'RELATIVE - Care provided in the home of a relative' is 'Yes'.
Depends on:
RELATIVE - Care provided in the home of a relative
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| Unrelated/Unlicensed Provider Background Check | ||
| Fingerprinting | Checkbox |
Check this box if fingerprinting has been completed through a Department-authorized vendor for the unrelated/unlicensed day care provider. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
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| CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care | Checkbox |
Check this box if the CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care has been completed or submitted. Fill only if 'Change of Day Care Provider' is 'Yes'.
Depends on:
Change of Day Care Provider
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| Check Box249 | CheckBox | |
| Check Box250 | CheckBox | |
| Fingerprint/CFS 718-D Submission Date | Date |
Enter the date the unrelated or unlicensed day care provider's Fingerprint receipt and CFS 718-D were submitted to the Background Check Unit. Fill only if 'Fingerprinting', 'CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care' is 'Yes' for any.
Depends on:
Fingerprinting, CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care
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| Background Check Results Provided Date | Date |
Enter the date the unrelated or unlicensed day care provider's full background history check results were provided to the worker. Fill only if 'Fingerprinting', 'CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care' is 'Yes' for any.
Depends on:
Fingerprinting, CFS 718-D Authorization for Background Check for Unlicensed and License-Exempt Child Care
|
| Work Schedule | ||
| Monday Work Schedule | Text |
Enter the applicant's work schedule for Monday, including start and end times.
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| Tuesday Work Schedule | Text |
Enter the applicant's work schedule for Tuesday, including start and end times.
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| Wednesday Work Schedule | Text |
Enter the applicant's work schedule for Wednesday, including start and end times.
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| Thursday Work Schedule | Text |
Enter the applicant's work schedule for Thursday, including start and end times.
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| Friday Work Schedule | Text |
Enter the applicant's work schedule for Friday, including start and end times.
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| Saturday Work Schedule | Text |
Enter the applicant's work schedule for Saturday, including start and end times.
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| Sunday Work Schedule | Text |
Enter the applicant's work schedule for Sunday, including start and end times.
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