Los Angeles CARES Child Care Application

The LA CARES Child Care Application is now CLOSED.

You cannot submit an application at this time.
FOR OFFICE USE ONLY. Please enter password to view OFFICE USE fields.

Click to view application
Los Angeles CARES Child Care Application

Additional funding for child care has been released. If you need child care in order to perform your work and meet the eligibility criteria below, please fill out this application and your local child care services agency will contact you.
Para ver este formulario en español, haga clic en el botón ‘English’ en la parte superior derecha de la página.
Please complete one form per household. In order to receive emergency child care services, you must meet the eligibility criteria below.
If the child you are requesting child care for lives with only one parent/caretaker who is legally/financially responsible for the child, please check the box below:

I am a single parent/caretaker
Eligibility Part A - Please check all of the eligibility categories which you are a part of:*

Parent of a child who is receiving Child Protective Services or at risk as defined by CPSParent of any child eligible through the Emergency Child Care Bridge Program for Foster ChildrenParent of a child with disabilities or special health care needs whose individualized education program (IEP) or individualized family support plans (IFSP) include early childhood education serviceFamily experiencing homelessnessDomestic violence (DV) survivorHealth Care Services and Emergency Services sector workerFood and Agriculture Sector workerChild Care and Education servicesEnergy SectorWater and Wastewater SectorTransportation and Logistics SectorCommunications and Information Technology SectorGovernment Operations and Other Community-Based Essential FunctionsCritical Manufacturing SectorFinancial Services SectorChemical SectorDefense Industrial Base SectorIndustrial, Commercial, Residential and Sheltering FacilitiesLow income family who is working in another employment sector that has re-opened
Eligibility Part B - In addition to the above, eligible parents/caregivers must also need child care to perform their work. Parent is required to be on site and not able to work remotely.*

Check this box to verify that the parent(s)/caregiver(s) listed on this application need child care to perform their work and are required to be on site.
Eligibility Part C - In addition to the above, if the family includes a two-parent household, both parents must either be working and required to work on site (not able to work remotely) or the second parent must be unable to provide care for the child due to incapacitation.*

Check this box to verify that both parents are either be working and required to work on site or the second parent must be unable to provide care for the child due to incapacitation.
Total hours of child care per week requested:*
If for any reason this attestation of being an Essential Worker, Low-Income Worker, or an At-Risk Population is found to be false or untrue, I understand that I will not have met an eligibility requirement for the receipt of emergency child care and my child may be subject to immediate disenrollment from any program he or she is attending.

By my signature below, I attest that the information provided above is true and correct.
Parent or Guardian Full Name:*
Parent or Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Please continue to Section I to complete the rest of your application.
Section I. Family Identification.
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)
Street Address*
Apartment or Unit number, if applicable
City*
Zip Code*
Section II. Family Income and Eligibility
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*

Clear
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 / Province

Zip Code
What is your category of employment? (pick the option that best represents your work)*
Does Parent/caretaker A have a second employer?*

YesNo
Second Employer Name *
Second Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
What is your category of employment? (pick the option that best represents your work)*
Parent/caretaker B
If Parent/caretaker B is incapacitated and unable to work, check the box below.

Parent/caretaker B is incapacitated
Employer Name*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
What is your category of employment? (pick the option that best represents your work)*
Does Parent B have a Second Employer?*

YesNo
Second Employer's Name *
Second Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Zip Code
What is your category of employment? (pick the option that best represents your work)*
Sorry, but you have entered a home address outside of Los Angeles County.

The Los Angeles CARES funding can only be given to residents of Los Angeles County. You cannot continue with this application if you live outside of Los Angeles County.
Section III. Family Size
How many people are in your family? Enter your family size below: *
Section IV. Data on Children.

List ALL children residing in the home and counted in the family size.
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 12 and under (21 and under if special needs) do you have that need child care?*

1234567 or more
Child 1. Full Name of Child Including Middle Initial*
Child 1. Gender*

MaleFemale
Child 1. Birth Date*

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

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

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderCaucasian
Child 1. Native Language: Select the child's primary native language below. *
Child 1. Do you know the provider you want?*

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. Birth Date*

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

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

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderCaucasian
Child 2. Native Language: Select the child's primary native language below. *
Child 2. Do you know the provider you want?*

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. Birth Date*

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

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

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderCaucasian
Child 3. Native Language: Select the child's primary native language below. *
Child 3. Do you know the provider you want?*

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. Birth Date*

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

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

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderCaucasian
Child 4. Native Language: Select the child's primary native language below. *
Child 4. Do you know the provider you want?*

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. Birth Date*

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

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

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderCaucasian
Child 5. Native Language: Select the child's primary native language below. *
Child 5. Do you know the provider you want?*

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. Birth Date*

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

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

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderCaucasian
Child 6. Native Language: Select the child's primary native language below. *
Child 6. Do you know the provider you want?*

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:
Section V. Certification and Signature of Parent/Caretaker

Read each statement in this section. To certify each statement, draw your initials with your mouse cursor or finger in the box provided.
I understand that I am self-certifying single parent status under penalty of perjury.
Parent Initials*

Clear
I understand that this is an application for a short-term care program. (approximately 3 months)
Parent Initials*

Clear
I understand that the information about my eligibility may be reviewed by the Child Care Alliance of Los Angeles, the County/City of Los Angeles, and your local child care agency.
Parent Initials*

Clear
I understand that this form represents an application and not a commitment to subsidized services. I understand that I will be notified if I am approved.
Parent Initials*

Clear
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*

Clear
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 *

Clear
Today's Date*

MonthDayYear
Date
Relationship to Child:*

ParentGrandparentGuardianFoster ParentOther
Agency Name:
Approval Status:

YesNoDuplicateOn Hold
Should be Empty:

Los Angeles CARES Child Care Application

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