Emergency Childcare Subsidy Application
Please complete the application below. Email dee.sbmh@gmail.com for additional information.
Email *
Parent/Guardian Information
Parent/Guardian Name
Home Phone #
Home Address
Financial Information
Include your Income information below.
Are you currently employed?
Clear selection
Employer Name
Current Income per week/month. You must indicate how often. (Example: $200/week or $800/month)
Total Family Income Last Year $
Household Size
Do you currently receive:
Financial Assistance Application is For These Children. Subsidy is only available for children ages 4 and up at the time of application.
Include NAME, SEX, AGE of each child. (Example: John Doe, 12, Boy)
Are your children currently enrolled in childcare?
Clear selection
If you answered yes to the previous question, please provide the childcare location.
Explanation of Financial Need/Circumstances.
Certification
I certify that all information contained in this application is truthful and can be verified. I understand that there is a limited amount of funding available for subsidy and that my eligibility for subsidy and continued participation in the program is subject to the availability of funding. If it is discovered that information was falsified on this application, my participation in the program may be terminated.
Type your full name below and include today's date to sign your application electronically. (Example: John Doe 8/10/20)
Please click the submit button below to send your application. Email dee.sbmh@gmail.com for additional questions.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of The Harvest Foundation. Report Abuse