ECEAP Application Child’s Name ________________________________________ Parent/Guardian For assistance completing this form, call: (xxx) xxx-xxxx or email: Family Info: Other Household Members (Optional) Relationship Age, Birthdate, First Name Last Name Gender to Child if under 19 if under 6 Family Info: Second Household If this child has one household, skip to section 3. Parent/Guardian name(s) Street Address City Zip Mailing address (if different) City Zip Phone Alternate Phone Email Household Situation Yes No Does this household receive subsidized housing, such as a housing voucher or cash assistance for housing? Does this household currently receive a Working Connections child care subsidy for this child? Yes No Income Received by Child’s Parent(s) or Guardian(s)
ECEAP Application Child’s Name ________________________________________ Parent/Guardian For assistance completing this form, call: (xxx) xxx-xxxx or email: Family Info: Other Household Members (Optional) First Name Last Name Gender Relationship to Child Age, if under 19 Birthdate, if under 6 Family Info: Second Household If this child has one household, skip to section 3. Parent/Guardian name(s) Street Address City Zip Mailing address (if different) City Zip Phone Alternate Phone Email Household Situation Does this household receive subsidized housing, such as a housing voucher or cash assistance for housing? Yes No Does this household currently receive a Working Connections child care subsidy for this child? Yes No Income Received by Child’s Parent(s) or Guardian(s)
Child_application.docx