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Cceh Children In Shelters Child Care Assistance Fund Application Form - Connecticut Coalition To End Homelessness Page 2

Contact Person: ____________________________________

Phone number_____________________________

Child(ren) to be in Care of above named Provider:

_________________________________________________________________________________________________________

Expected Dates of Childcare Assistance Coverage (not to exceed 8 weeks):

Start Date _______________

End Date ________________

If other children in household are in need of care with a different provider:

Additional Childcare Provider Information:

Name of Child Care Provider________________________________________________________________________

Address: _____________________________________________________________________________________________

Mailing Address for Payment, if different from above:

________________________________________________________________________________________________________

Contact Person: ____________________________________

Phone number_____________________________

Child(ren) to be in Care of above named Provider:

_________________________________________________________________________________________________________

Expected Dates of Childcare Assistance Coverage (not to exceed 8 weeks):

Start Date _______________

End Date ________________

Has all provider and parent information been verified by shelter or CT-RRP staff?

______Yes

______No

Have parent, childcare provider and shelter/CT-RRP staff signed agreement?

______Yes

______No

Parent Signature______________________________________________

Date______________________

Shelter/CT-RRP Staff Signature __________________________________ Date

___________________

________________________________________________________________________________________________________

For CCEH use only:

Date request received____________

Reviewed By: _____________________________________ Signature: _____________________________________

Outcome: ______ Approved ______ Denied

Date approved _____________ Date Denied ______________

Reason for denial: ___________________________

Person notified: _____________________________________

Date___________________

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Cceh Children In Shelters Child Care Assistance Fund Application Form - Connecticut Coalition To End Homelessness Page 2