Childcare Resources of Indian River

Childcare Resources of Indian River, Inc. Preliminary Application

Thank you for your interest in Childcare Resources of Indian River. Currently, we do not have an opening for your child. To be placed on the Childcare Resources of Indian River waiting list, please complete the following information and return to us as quickly as possible. You must reside in Indian River County, and be employed a minimum of 30 hours per week or be a full time student to apply for Childcare Resources of Indian River assistance.

If you change addresses or phone numbers, please notify our office immediately. If we cannot reach you when an opening occurs because you have moved or changed phone numbers, you will lose your slot.

Section 1: General Information
Applicants name:
How many dependent children are living in your family household?
If married, are both you and your spouse employed 30 or more hours weekly or full-time students?	Yes No
If single, are you employed 30 or more hours weekly or a full-time student?	Yes No
Section 2: Child or children's Information
First child's full name:
Child's Birthday:
Age:
Sex:	Boy Girl
Child resides with:	Mother Father Both
or Other:
Race:
Second child's full name:
Child's Birthday:
Age:
Sex:	Boy Girl
Child resides with:	Mother Father Both
or Other:
Race:
Section 3: Mother's information
Mother's name:
Status:	Married Single
Home phone:
Work phone:
Cell phone:
email:
Mailing Address:
Hours worked per week:
Wages earned per week (before taxes)
Annual Wages (before taxes)
Child support/alimony you receive per month:
Other income received each month (food stamps, social security benefits, unemployment, etc.)
If student:	Full time Part time
Section 4: Father's information
Father's name:
Status:	Married Single
Home phone:
Work phone:
Cell phone:
Email:
Mailing address:
Hours worked per week:
Wages earned per week (before taxes)
Annual Wages (before taxes)
Child support/alimony you receive per month:
Other income received each month (food stamps, social security benefits, unemployment, etc.)
If student:	Full time Part time
Verification No.:*