Snohomish County Child Care Choice Intake Form "*" indicates required fields Household InformationPreferred PronounOptional Parent/CaregiverEnter first and last name of primary caregiver. First Last Birth DateNeeded for database entry MM slash DD slash YYYY Preferred PronounOptional Second parent/caregiver if applicableFirst and last name of secondary caregiver. First Last Birth DateNeeded for database entry MM slash DD slash YYYY Primary Caregiver PhonePrimary Caregiver Email Address Street Address City ZIP Code Preferred Language Interpretation/Translation Needs Interpreter Translated documents Client prefers no interpreter ChildrenNameBirthdate - format mm/dd/yyyy Add RemoveHousehold TypePlease choose a head of household type.Single MotherSingle FatherTwo parentsGrandparent(s)GuardianOther relativeNumber of people in your household including parents/guardians and children below age 18 unless enrolled in high school.Head of Household RaceAmerican Indian/Alaska NativeBlack/African-AmericanAsianWhiteMulti-racialNative Hawaiian/Pacific IslanderOtherUnknownHead of Household Ethnicicy Hispanic or Latinx Not Hispanic or Latinx Does family receive the Working Connections Child Care subsidy? Yes No Request for Financial AssistanceIs one or both parents/caregivers employed? Yes No Employer 1 Employer 2 HiddenEmployer 1 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HiddenEmployer 2 Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HiddenEmployer 1 PhoneHiddenEmployer 2 PhoneIs one or both parents/caregivers unemployed and looking for work? Yes No Is one or both parents/caregivers unemployed and enrolled in work training or vocational school? Yes No What program?Enter the program name, affiliated school or entity, and location. (e.g. Home Care Health Training, Catholic Community Services, Edmonds, WA) Target completion dateEnter estimated training end date. MM slash DD slash YYYY Referral InformationReferral ProgramName of community partner referring clientTake the Next StepCares of WashingtonOrion IndustriesTRAK AssociatesHope HouseOpportunity Council / Internal referralOtherReferral Contact First Last HiddenReferral Contact PhoneHiddenReferral Contact Email Child Care InformationCurrent situationPlease describe current work or vocational program. How can child care assistance help client achieve employment or career goals?Is child(ren) enrolled in a licensed child care program? Yes No Child Care Program Child Care Provider Contact Name First Last Contact Title Child Care Program Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code W9 on file?Is this program new to Opportunity Council vouchers? If yes, be sure to send new vendor information. Yes Not yet Target Child Care Coverage Start Date Month Day Year Target Child Care Coverage End Date Month Day Year Monthly enrollment feesEnter monthly rates for childcare. If the provider charged weekly rates, multiply weekly rate by 4.3 for estimated monthly.Other monthly feesEnter estimated total for other fees, e.g. activity fees, field trips, etc.Please attach a current or projected bill from a licensed child care care or licensed family home.You can attached a scanned pdf or upload a clear picture of the bill with your phone. Accepted file types include doc, docs, pdf, xls, jpeg, and png. Drop files here or Select files Accepted file types: doc, png, jpg, pdf, xls, xlsx, png, docx, Max. file size: 25 MB. Income VerificationFamilies may qualify for the Child Care Voucher program if enrolled in an eligible program or via current income if household earns up to 60% of the area median income. Is the family enrolled in one of the following programs? 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 Monthly IncomeAnnual IncomeProof of Income DocumentationPlease upload an enrollment letter or other documentation to show enrollment in a public benefits program. If not enrolled in a public benefit program, paystubs for the last 30 days are okay as long as the pics are clear and not too fuzzy. Max. file size: 25 MB.Approval NotesNavigator Approval NotesDescribe logic used to determine total months of approval and approval amounts. More information is better than too little.Number of monthsEnter the total number of months for initial approval. Can be extended if needed with approval .Maximum AmountAuto-calculates the maximum amount for initial approval. Multiplies monthly rate by the number of estimated months of care plus fees.Navigator*Chelsey CraginLiz SteeleRose MarcotteNavigator Email* Program Coordinator Email Assistant Director Email ELAFS Director Email Fiscal Technician Email
