Families | ESCCS Pilot Program

Your Name *

Street

Street2

City

County *

State

Zip

Phone Number

Your Email *

Preferred Contact Method

Email

Text

Call

Number Of People In Household

Number Of Adults

Number of Children (Under 18)

Employer

My Employer Isn't Listed

Employer Contact Information

Employee Work ID (if applicable)

Employment Start Date

Monthly Gross Income (Before Tax)

Most Recent Pay Stub

Second Recent Pay Stub

Partner/Spouse Monthly Gross Income

Partner/Spouse Employment Start Date

Partner/Spouse Most Recent Pay Stub

Partner/Spouse Second Recent Pay Stub

Total Monthly Amount Of Additional Income

Documentation For Additional Income

Child Care Provider

My Provider Isn't Listed

Provider Contact Info

I Don't Have a Child Care Program

Receiving Child Care Assistance Benefits through DSS

Denied Child Care Assistance through DSS

Family Agreement (to participate you must agree to the following policies by checking each box) *

I will notify ESCCS staff if my employment status changes

I understand that I am 100% responsible for ALL childcare costs as of employment change

I will notify the ESCCS staff if I change my childcare arrangements (provider, hours, days, other)

I understand that I will be responsible for any legal fees incurred to collect any childcare costs after change of employment

I certify that all application information and documents provided are correct/accurate/complete to the best of my knowledge

I understand falsification/misrepresentation/omission will cause denial or immedate termination from ESCCS Hub Staff

I agree if I do not qualify for ESCCS due to income, my employer can be notified

I agree to be respectful in all communication regarding the program

I have read and acknowledged all items in the Family Agreement *

Subject *

Childcare Type

Provider

Parent

Employer

New Family Application

Eligibility