Arkansas Department of Human Services

ARKANSAS DEPARTMENT OF HUMAN SERVICES

Division of Childcare and Early Childhood Education

Childcare Referral (Protective Services/Foster Care/Supportive Services)

CHRIS Case ID: / CHRIS Client ID: / Childcare Authorization Number:
TYPE OF CASE: Protective Services Foster Care IV-E Foster Care NON-IV-E Supportive Services

CHILDCARE INFORMATION New Renew Change Reason for Change:

Effective Date of Change:

Facility Name: / Facility #
Facility Phone #
Address: / County:
Effective Dates: / Beginning: / Ending:
Times Needed: IN:
IN: / am pm
am pm / OUT:
OUT: / am pm
am pm / Total Hour(s):
Total Minute(s):
Reason (if greater than 10 Hours per day):
Days Needed: Monday / Tuesday / Wednesday / Thursday / Friday Saturday Sunday
Reason (if care is needed on Weekends):
Type Needed: Part Time Half Time Full Time Night Care Weekends
EXCEPTION SCHEDULE : School Age Children Full Days (School Breaks/Holidays) or Non-School Age Children with variable schedules
Dates Times Needed Dates Hr(s)/Day Min(s)/Day Care Type
–
–
–
– / IN:
IN:
IN:
IN: / am pm
am pm
am pm
am pm / OUT:
OUT:
OUT:
OUT: / am pm
am pm
am pm
am pm

CASE INFORMATION

CHILD / Y N
First Name / Last Name / DOB / Age / SSN / SSN Verified
Race: American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White Unable to Determine
Gender: FM Ethnicity: Not Hispanic or LatinoHispanic or LatinoUnable to Determine Reason for Childcare: Relationship to Adult:
PARENT / Y N
First Name / Last Name / DOB / Age / SSN / SSN Verified
Race: American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Other Pacific Islander White Unable to Determine
Physical Address:
Gender: MaleFemale Ethnicity: Hispanic or LatinoNot Hispanic or LatinoUnable to Determine County of Placement:
SUPPORTIVE SERVICES ONLY Gross Monthly Income: $ Please provide proof of income – last 4 pay stubs from employer

APPROVAL INFORMATION

REQUESTED BY:
DCFS Worker / Date / County / Phone
RECOMMENDED: / Y N
DCFS Supervisor Signature / Date
APPROVED: / Y N
Financial Support Staff Signature / Date