"*" indicates required fields Household InformationPreferred PronounIf knownParent/Caregiver*Enter first and last name of primary caregiver. First Last Primary Caregiver Email Primary Caregiver Phone*This field is hidden when viewing the formPreferred PronounThis field is hidden when viewing the formSecond parent/caregiver if applicablePlease enter first and last name of secondary caregiver. First Last Preferred LanguageReferral ProgramCares of WashingtonHousing HopeOrion IndustriesTake the Next StepTRAC AssociatesOpportunity CouncilOtherChildren NamesClick on the plus sign at end of row to add another child.First NameLast Name Add RemoveReferral Contact First Last Referral Contact PhoneReferral Contact Email Current situation*Please describe the family's current work or vocational program. Anything else we should know? Interpretation preferences, strengths/assets, challenges?Annual IncomeArea Median Income (AMI)Families can make up to 60% of AMI upon program intake. 30% AMI 50% AMI 60% AMI >60% AMI This field is hidden when viewing the formIncome VerificationFamily income can total up to 60% of AMI for participation in the Child Care Choice program.Do you know if the family is enrolled in any of the following programs? If so, the family is income eligible for a child care choice voucher. Children's Health Insurance Program Childcare Subsidies through the Child Care and Development Fund (CCDF) Medicaid Temporary Assistance for Needy Families (TANF) Supplemental Nutrition Assistance Program (SNAP) Free and Reduced-priced lunch (NSLP) and/or school breakfast (SBP) Medicare Part D Low-income subsidies Supplemental Security Income Head Start or Early Head Start Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Section 8 Vouchers Low-income Home Energy Assistance Program (LIHEAP) Pell Grants Early Childhood Education Assistance Program (ECEAP) State Food Assistance Program (FAP) LEP Pathway Refugee Cash Assistance (RCA) PUD Electric and water rate discount None of these programs I don't know
