PRELIMINARY APPLICATION
PRELIMINARY APPLICATION 2022 Summer Only No.: ____ NAME: ___________________________________________________ FAMILY SIZE: _______ SS#________________________(required)_________________Single_______________Married MAILING ADDRESS: ___________________________________________________________ ___________________________________________________________ TELEPHONE NOS.: ____________________ _________________ ________________ WORK CELL HOME EMAIL ADDRESS: _____________________________________________________________ PLACE OF EMPLOYMENT: _______________________________Phone#________________ ARE YOU A TEEN PARENT? YES NO ANNUAL INCOME: $_________________________ NAME OF CHILD (REN) _________________________ DOB: ________________ _________________________ DOB: ________________ Have you applied for or are you receiving childcare services from any of the following? …
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PRELIMINARY APPLICATION 2022 Summer Only No.: ____ NAME: ___________________________________________________ FAMILY SIZE: _______ SS#________________________(required)_________________Single_______________Married MAILING ADDRESS: ___________________________________________________________ ___________________________________________________________ TELEPHONE NOS.: ____________________ _________________ ________________ WORK CELL HOME EMAIL ADDRESS: _____________________________________________________________ PLACE OF EMPLOYMENT: _______________________________Phone#________________ ARE YOU A TEEN PARENT? YES NO ANNUAL INCOME: $_________________________ NAME OF CHILD (REN) _________________________ DOB: ________________ _________________________ DOB: ________________ Have you applied for or are you receiving childcare services from any of the following? [ ] Head Start [ ] Early Head Start [ ] AmeriCorps [ ] labor [ ] Military [ ] Other ______________________ __________________ Signature of Applicant Date OFFICIAL USE ONLY [ ] ELIGIBILITY [ ] COMPLETED [ ] NO LONGER [ ] NO SHOW [ ] OTHER [ ] INELIGIBILITY [ ] IN SUFFICIENT HOURS [ ] NOT IN A COMPONENT [ ] OVER QUALIFIED With the current information provided, you have been found eligible for child subsidy funding. However, upon availability of funds, you will be re-evaluated and if you continue to be found eligible, you will receive childcare subsidy funding. Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980, (340)772-7147