Please put NA for any required fields that do not apply.
Family size consists of parents, those in the home who can be claimed as dependents on a federal tax return, or a minor who is the responsibility of the parent/applicant. Income does not include federal or state assistance or child support. A family's monthly income is the gross income before adjustments are made for taxes, which can be referred to as gross earnings or gross pay.
After you submit this form, you will be contacted by Workforce Solutions staff and asked to provide additional personal information over the phone which will include which child care provider you have chosen.
Please select the category that best describes your job. Only one parent is required to be working in the Service Industry.
Current paystub (within last 30 days), employment verification form signed by employer, or signed letter of employment on company letterhead with company contact information.
I certify that I qualify as a Service Industry Worker, require child care to work, my family income is at or below 75% SMI and the address I have provided is my current residential address. I also certify that I am meeting the participation requirements for my household size (25 hrs. per week for single parent/50 hrs. per week for two-parent household).
I understand that child care is only provided for 12 months and I will have to reapply for child care services at the end of the 12-month timeframe. Upon re-applying I may be subject to a waitlist and will not have child care services while on the waitlist or during the eligibility process.
I certify that all information provided on this form is accurate and child care may be terminated if any of this information is found to be inaccurate. I understand that giving false information may constitute fraud and could result in prosecution and/or repayment of money for services for which I was not entitled.
By checking the "I agree" box above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
- Proof of employment in a qualifying occupation.
- Proof of citizenship/legal immigration status for children needing care.
- Completed and signed SIR Child Care Enrollment Form (this application).
Workforce Solutions is an equal opportunity/employer program. Auxiliary aids and services are available upon request to individuals with disabilities. Relay: 1-800-735-2989 (TTY) / 711 (Voice). This service is funded in whole or in part with federal funds. More detailed information is located on the Public Information page on the Board’s website.
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