Wait List Assessment for Child Care Services

2626 John Ben Shepperd Pkwy

Bldg. D

Odessa, Texas 79761

432-367-3332

Applicant is: / Applicant is:
Check all that apply –
if none apply, please leave blank and continue
Currently receiving child care assistance from
a different area of Texas
A qualified veteran
A foster youth
Homeless
A parent on military deployment
A teen parent
A parent whose child has a disability / Check all that apply –
if none apply, please leave blank and continue
TANF recipient in last 12months
Parent participating in WorkforceSolutions WIOAprogram
Parent participating in WorkforceSolutions NCPprogram
Referred by Workforce Solutions Partner Please list name of ReferringAgency:

ParentName:DateofBirth:MaleFemale

MailingAddress:Apt #:County:

ResidenceAddress:Apt #:County:

CityandZip:*Social Security#:--

DaytimeTelephoneNumber: Ethnicity:

Hispanic or Latino YesNo

Msg.Number

Race:

WhiteBlack or African AmericanIndianorNativeHawaiianorAsianUnknown AmericanAlaskanNative Other PacificIslander

MaritalStatus:Single MarriedDivorcedSeparatedWidowed

EmployerName:Gross monthlysalary:

Rate of payperhour:Avg. # of work hours perweek:

How often paid? DailyWeekly Everyother week Twice Monthly Monthly

Training information: Currently enrolled at:

2nd Parent

Number of semester hours currentlyenrolled:

Name (if living in thehome):

DateofBirth: Ethnicity:

*Social Security#:--

 Male Female

Hispanic or Latino YesNo

Race:

WhiteBlack or African AmericanIndianorNativeHawaiianorAsianUnknown AmericanAlaskanNative Other PacificIslander

EmployerName:Gross monthlysalary:

Rate of payperhour:Avg. # of work hours perweek:

How often paid? DailyWeekly Everyother week Twice Monthly Monthly

Training information: Currently enrolled at:

Number of semester hours currentlyenrolled:

Total Household Monthly Income: What is your monthly gross(before taxes are taken out) total household income?

$

What is the total Number of family members in your household? (includes child/ren eligible to receive child care services, the parents of that child living in the home, and householddependents)

First and Last Name of each child living in the Household / Date Of Birth / *Social Security Number / Race
W = White B=Black/African
American
AI= American Indian or Alaskan Native
PI = Native Hawaiian or Other Pacific Islander A= Asian
U= Unknown / Ethnicity Hispanic or Latino Yes or No / Child Care Needed Yes or No / Sex
M
or F

Please choose one method of notification when funding becomes available:

 Please notify me by e-mailat

 Please notify me by U.S. Postal Service to my mailing address.

By signing below, I understand it is my responsibility to contact Child Care Service (CCS) at 432-367-3332 if any changes to this application should occur, this includes address and phone

numbers. I understand it is my responsibility to call the CCS office at 432-367-3332 every 30 days to keep my name on the wait list. By not calling every 30 days, I am authorizing CCS to remove my name from the wait list.

If you choose a relative provider, please ask for additional information and paperwork



NameDate

This assessment may be mailed or hand delivered to our office.

*Social Security Number is Optional

Please visit our website at information on choosing child care providers.