Los Angeles CARES Child Care Application

The LA CARES Child Care Application is now CLOSED.

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- 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:
- Eligibility Part A - Please check all of the eligibility categories which you are a part of:
- 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.
- 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.
- 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?
- 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.
- 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?
- 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?
- Child 1. Full Name of Child Including Middle Initial
- Child 1. Gender
- Child 1. Birth Date
  
  MonthDayYear
  Date
- Child 1. Ethnicity: Select “Y” if the child is Hispanic or Latino. Otherwise, select “N”.
- Child 1. Race: At least one race must be selected, but you may enter all codes that apply for each child.
- Child 1. Native Language: Select the child's primary native language below.
- Child 1. Do you know the provider you want?
- 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
- Child 2. Birth Date
  
  MonthDayYear
  Date
- Child 2. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.
- Child 2. Race: At least one code must be entered, but you may enter all codes that apply for each child.
- Child 2. Native Language: Select the child's primary native language below.
- Child 2. Do you know the provider you want?
- 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
- Child 3. Birth Date
  
  MonthDayYear
  Date
- Child 3. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.
- Child 3. Race: At least one code must be entered, but you may enter all codes that apply for each child.
- Child 3. Native Language: Select the child's primary native language below.
- Child 3. Do you know the provider you want?
- 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
- Child 4. Birth Date
  
  MonthDayYear
  Date
- Child 4. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.
- Child 4. Race: At least one code must be entered, but you may enter all codes that apply for each child.
- Child 4. Native Language: Select the child's primary native language below.
- Child 4. Do you know the provider you want?
- 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
- Child 5. Birth Date
  
  MonthDayYear
  Date
- Child 5. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.
- Child 5. Race: At least one code must be entered, but you may enter all codes that apply for each child.
- Child 5. Native Language: Select the child's primary native language below.
- Child 5. Do you know the provider you want?
- 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
- Child 6. Birth Date
  
  MonthDayYear
  Date
- Child 6. Ethnicity: Enter “Y” if the child is Hispanic or Latino. Otherwise, enter “N”.
- Child 6. Race: At least one code must be entered, but you may enter all codes that apply for each child.
- Child 6. Native Language: Select the child's primary native language below.
- Child 6. Do you know the provider you want?
- 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:
  
  Other
- Agency Name:
- Approval Status:
- 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