CCRC COVID-19 Emergency Child Care Application

State regulations require a formal application and certification for early learning and care services. This form must be completed by an agency representative in consultation with the family. The agency must certify family eligibility prior to beginning services.

In order to receive emergency child care services, you must be a COVID-19 essential worker.*

Check this box if you are eligible for Emergency Child care due to COVID-19 as stated above.

If the child lives with only one parent/caretaker who is legally/financially responsible for the child, check the box below:

Single parent/caretaker

Parent/caretaker A:

For the first adult living in the same household as the child(ren), complete all items in Section I, including address information. For the purposes of these instructions and the certification of eligibility, a parent/caretaker shall be a person who has responsibility for the child. Thus, “parent/caretaker” could refer, for example, to a biological parent, a stepparent, a grandparent, a foster or adoptive parent, or a legal guardian.

Name of parent/caretaker (full name, including middle initial)*

Email address of parent/caretaker*

Phone number (cell or home)*

Phone number (work/school)

Parent/caretaker B:

If a second parent/caretaker lives in the same household as the child and is included in the calculation of family size, complete all items in Section I B.

Name of parent/caretaker (full name, including middle initial)*

Phone number (cell or home)*

Phone number (work/school)

Address*

Street address

Street Address Line 2

City

Zip

State*

Which county are you located in?*

xFIPS code

1. Income and Eligibility Information:

What is your family's gross monthly family income?*

Draw your initials below to certify that the total family income stated is true and correct.

Parent Initials (Iniciales del padre/guardian)*

COVID-19 Emergency Child care Self- Certification (Attach Documentation)

For each adult listed in Section I above, enter all of your employer information below.

Parent/caretaker A

Employer Name*

Employer’s Address*

Street Address

Street Address Line 2

CityState

Zip Code

Does Parent/caretaker A have a second employer?*

YesNo

Second Employer Name *

Second Employer’s Address *

Street Address

Street Address Line 2

CityState

Zip Code

Days and working/training hours: Enter the beginning and ending hours for each day that the parent is employed. (e.g. 6:00am)*

	Mon.	Tue.	Wed.	Thu.	Fri.	Sat.	Sun.
From:
To:

Parent/caretaker B

Employer Name*

Employer’s Address*

Street Address

Street Address Line 2

CityState

Zip Code

Does Parent B have a Second Employer?*

YesNo

Second Employer's Name *

Second Employer’s Address*

Street Address

Street Address Line 2

CityState

Zip Code

Days and working/training hours: Enter the beginning and ending hours for each day that the parent is employed. (e.g. 6:00am)*

	Mon.	Tues.	Wed.	Thu.	Fri.	Sat.	Sun.
From:
To:

How many people are in your family? Enter your family size below: *

Note:

When a child and his or her siblings are living in a household that does not include their biological, or adoptive parent(s), “family” shall be considered the child and related siblings. List only the children of this” family” who are eighteen and under.

Complete for all children eighteen and under residing in the household

How many children eighteen and under do you have? [If you have 7 or more children, only the first six will show on the completed PDF]*

Child 1. Full Name of Child Including Middle Initial*

Child 1. Gender*

MaleFemale

Child 1. xGender

MaleFemale

Child 1. Birth Date*

Date

Child 1. Ethnicity: Select “Y” if the child is Hispanic or Latino. Otherwise, select “N”.*

YN

Child 1. xEthnicity

Child 1. Race: At least one race must be selected, but you may enter all codes that apply for each child.*

Child 1. xRace

Child 1. Native Language: Select the child's primary native language below. *

Child 1. xNative Language Code

Child 1. Child is English Learner? (School age ONLY)

YesNo

Child 1. xChild is English Learner? (School age ONLY)

YesNo

Child 1. Provider/site name:

Child 1. Provider/site address:

Street Address

Street Address Line 2

City

Zip Code

Child 1. Provider/site phone number:

Child 2. Full Name of Child Including Middle Initial*

Child 2. Gender*

MaleFemale

Child 2. xGender

MaleFemale

Child 2. Birth Date*

Date

Child 2. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.*

YN

Child 2. xEthnicity

Child 2. Race: At least one code must be entered, but you may enter all codes that apply for each child.*

Child 2. xRace

Child 2. Native Language: Select the child's primary native language below. *

Child 2. xNative Language Code

Child 2. Child is English Learner? (School age ONLY)

YesNo

Child 2. xChild is English Learner? (School age ONLY)

YesNo

Child 2. Provider/site name:

Child 2. Provider/site address:

Street Address

Street Address Line 2

City

Zip Code

Child 2. Provider/site phone number:

Child 3. Full Name of Child Including Middle Initial*

Child 3. Gender*

MaleFemale

Child 3. xGender

MaleFemale

Child 3. Birth Date*

Date

Child 3. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.*

YN

Child 3. xEthnicity

Child 3. Race: At least one code must be entered, but you may enter all codes that apply for each child.*

Child 3. xRace

Child 3. Native Language: Select the child's primary native language below. *

Child 3. xNative Language Code

Child 3. Child is English Learner? (School age ONLY)

YesNo

Child 3. xChild is English Learner? (School age ONLY)

YesNo

Child 3. Provider/site name:

Child 3. Provider/site address:

Street Address

Street Address Line 2

City

Zip Code

Child 3. Provider/site phone number:

Child 4. Full Name Including Middle Initial*

Child 4. Gender*

MaleFemale

Child 4. xGender

MaleFemale

Child 4. Birth Date*

Date

Child 4. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.*

YN

Child 4. xEthnicity

Child 4. Race: At least one code must be entered, but you may enter all codes that apply for each child.*

Child 4. xRace

Child 4. Native Language: Select the child's primary native language below. *

Child 4. xNative Language Code

Child 4. Child is English Learner? (School age ONLY)

YesNo

Child 4. xChild is English Learner? (School age ONLY)

YesNo

Child 4. Provider/site name:

Child 4. Provider/site address:

Street Address

Street Address Line 2

City

Zip Code

Child 4. Provider/site phone number:

Child 5. Full Name Including Middle Initial*

Child 5. Gender*

MaleFemale

Child 5. xGender

MaleFemale

Child 5. Birth Date*

Date

Child 5. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.*

YN

Child 5. xEthnicity

Child 5. Race: At least one code must be entered, but you may enter all codes that apply for each child.*

Child 5. xRace

Child 5. Native Language: Select the child's primary native language below. *

Child 5. xNative Language Code

Child 5. Child is English Learner? (School age ONLY)

YesNo

Child 5. xChild is English Learner? (School age ONLY)

YesNo

Child 5. Provider/site name:

Child 5. Provider/site address:

Street Address

Street Address Line 2

City

Zip Code

Child 5. Provider/site phone number:

Child 6. Full Name Including Middle Initial*

Child 6. Gender*

MaleFemale

Child 6. xGender

MaleFemale

Child 6. Birth Date*

Date

Child 6. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.*

YN

Child 6. xEthnicity

Child 6. Race: At least one code must be entered, but you may enter all codes that apply for each child.*

Child 6. xRace

Child 6. Native Language: Select the child's primary native language below. *

Child 6. xNative Language Code

Child 6. Child is English Learner? (School age ONLY)

YesNo

Child 6. xChild is English Learner? (School age ONLY)

YesNo

Child 6. Provider/site name:

Child 6. Provider/site address:

Street Address

Street Address Line 2

City

Zip Code

Child 6. Provider/site phone number:

I understand that I am self-certifying single parent status under penalty of perjury.

Parent Initials (Iniciales del padre/guardian)*

I understand that as a condition of receiving Emergency Child care services, I am not eligible for 12-month eligibility.

Parent Initials (Iniciales del padre/guardian)*

I understand that the information about my eligibility may be reviewed by representatives of the State of California, the federal government, independent auditors, or others as necessary for the administration of the program.

Parent Initials (Iniciales del padre/guardian) *

I understand that this certification is not complete until all documentation is submitted and this form has been signed and dated by me and reviewed, signed, and dated by an agency representative.

Parent Initials (Iniciales del padre/guardian)*

I certify that my family assets do not exceed $1,000,000; Child Care and Development Block Grant Act Section 658 p (4)(B).

Parent Initials (Iniciales del padre/guardian) *

I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

To certify this statement, draw your signature below with your mouse cursor or finger.

Signature / Firma*

Today's Date*

Date

Relationship to Child:*

FOR OFFICE USE ONLY

Do not check this box unless you are Child Care Resource Center staff

Agency Name:

Insert the name of the agency providing child care services in this space.

Which office are you located in?

HQAVSBVV

Family Identification/Case No.:

A Family Identification Number (FIN) or Family Case Number (FCN) must be assigned to each family. Enter the unique FIN above.

Initial Subsidized Service Date:

This is the earliest month and year that the child(ren), as listed on this COVID-19 2020, first started receiving subsidized child care services from your agency. Every Form COVID-19 2020 must have a month and year entered in this field. This information is for data reporting purposes.

Case Specialist Email:

example@example.com

Number of children served:

Eligibility Status:

ApprovedDenied

Site Name:

Date Notice of Action Sent (Attach copy)

Date

Date Notice of Action Given (Attach copy)

Date

First date of subsidized service

Date

Last date of enrollment

Date

Signature of Authorized Agency Representative

Title

Phone number

Date

Signature of Supervisor (Optional)

Title

Phone number

Date

Child 1. Adjustment Factor Code: If no adjustment factor is used, leave this box blank.

Child 1. xAdjustment Factor Code

Child 1. Program Code

Child 1. xProgram Code

Child 1. Type of Care Code

Child 1. xType of Care Code

Child 1. Hours of Care per Day: Use the lower line (marked “V”) to indicate the amount of time needed during the COVID-19 State of Emergency. For preschool-age children, use only the upper line to record the amount of care needed.

	Mon.	Tue.	Wed.	Thu.	Fri.	Sat.	Sun.
S:
V:

Child 2. Adjustment Factor Code: If no adjustment factor is used, leave this box blank.

Child 2. xAdjustment Factor Code

Child 2. Program Code

Child 2. xProgram Code

Child 2. Type of Care Code

Child 2. xType of Care Code

Child 2. Hours of Care per Day: Use the lower line (marked “V”) to indicate the amount of time needed during the COVID-19 State of Emergency. For preschool-age children, use only the upper line to record the amount of care needed.

	Mon.	Tue.	Wed.	Thu.	Fri.	Sat.	Sun.
S:
V:

Child 3. Adjustment Factor Code: If no adjustment factor is used, leave this box blank.

Child 3. xAdjustment Factor Code

Child 3. Program Code

Child 3. xProgram Code

Child 3. Type of Care Code

3. xType of Care Code

Child 3. Hours of Care per Day: Use the lower line (marked “V”) to indicate the amount of time needed during the COVID-19 State of Emergency. For preschool-age children, use only the upper line to record the amount of care needed.

	Mon.	Tue.	Wed.	Thu.	Fri.	Sat.	Sun.
S:
V:

Child 4. Adjustment Factor Code: If no adjustment factor is used, leave this box blank.

Child 4. xAdjustment Factor Code

Child 4. Program Code

Child 4. xProgram Code

Child 4. Type of Care Code

Child 4. xType of Care Code

Child 4. Hours of Care per Day: Use the lower line (marked “V”) to indicate the amount of time needed during the COVID-19 State of Emergency. For preschool-age children, use only the upper line to record the amount of care needed.

	Mon.	Tue.	Wed.	Thu.	Fri.	Sat.	Sun.
S:
V:

Child 5. Adjustment Factor Code: If no adjustment factor is used, leave this box blank.

Child 5. xAdjustment Factor Code

Child 5. Program Code

Child 5. xProgram Code

Child 5. Type of Care Code

Child 5. xType of Care Code

Child 5. Hours of Care per Day: Use the lower line (marked “V”) to indicate the amount of time needed during the COVID-19 State of Emergency. For preschool-age children, use only the upper line to record the amount of care needed.

	Mon.	Tue.	Wed.	Thu.	Fri.	Sat.	Sun.
S:
V:

Child 6. Adjustment Factor Code: If no adjustment factor is used, leave this box blank.

Child 6. xAdjustment Factor Code

Child 6. Program Code

Child 6. xProgram Code

Child 6. Type of Care Code

Child 6. xType of Care Code

Child 6. Hours of Care per Day: Use the lower line (marked “V”) to indicate the amount of time needed during the COVID-19 State of Emergency. For preschool-age children, use only the upper line to record the amount of care needed.

	Mon.	Tue.	Wed.	Thu.	Fri.	Sat.	Sun.
S:
V:

CCRC is no longer accepting applications for emergency child care. We will make an announcement if additional opportunities become available in the future.

Section I. Family Identification.

Section II. Family Income and Eligibility

Section III. Family Size

Section IV. Data on Children.

Section V. Certification and Signature of Parent/Caretaker

Section VI. For Office Use Only.

SELF-CERTIFICATION OF ELIGIBILITY FOR COVID-19 EMERGENCY CHILD CARE