Child Care Services Change Form

2. If you are currently receiving child care services or you are on the waiting list for services, you have 14 days to report any changes in eligibility to Child Care Services.

4. Please complete the following information:

6. First Name:*

7. Last Name:*

9. Email Address:*

10. Contact Number: *

12. Date of Birth: *

14. Are you on the waiting list for services?

    1. YES

    1. NO

16. Would you like to update your name to the waiting list for services?

    1. YES

    1. NO

18. Report Changes *

    Please select ALL changes you want to report

    1. Address Change
    2. Phone number Change
    3. Family Size Change
    4. Income Change
    5. Employment/ School Change
    6. Child Care Change
    7. Voluntarily Withdraw my child from services
    8. Other
20. New Address:*

22. City:*

24. State:*

26. Zip Code:*

28. Home Phone Number:

30. Cell Phone Number:

32. Other Contact Number:

34. Best Time to Contact You at Home:
    -- Select One --AnytimeMorningAfternoon

36. Best Time to Contact You on Cell Phone:
    -- Select One --AnytimeMorningAfternoon

38. Indicate the reason for the change in family size:
    -- Select One --New BabyHousehold Member Moved InHousehold Member Moved OutChange in Marital Status

    Complete the information of the household member than needs to be added/removed from the household

40. First Name:

    Information of New HH Member

42. Last Name:

44. Date of Birth:

46. New household member is a(n):
    -- Select One --Adult (over 18 yrs old)Child (ages 0-18)

48. Relationship of the new household member:
    -- Select One --My Biological ChildSpouseBoyfriend/GirlfriendNot my Biological Child

50. New household member is:
    -- Select One --WorkingAttending SchoolNeitherBoth

52. Name of Employer and/or School of new household member (if applicable):

54. Indicate the income source that changed:
    -- Select One --Employment IncomeSelf Employment IncomeChild SupportTANFSocial Security IncomeDisability IncomeWorkers CompensationBonus IncomeOther

56. How did the income change:
    -- Select One --Pay RaiseIncreasedDecreasedBonusStopped ReceivingChanged JobsGot a 2nd JobLost JobOn Medical/Maternity LeaveOther (please explain below)

58. If other, please explain:

60. Effective Date of Income Change:

62. New Employer/Training Name:*

64. Last day at previous activity:

65. Start date of new activity (if applicable):

67. Is this change to your Employment/Training information additional information that needs to be added to your case?
    -- Select One --YesNo

69. Is your change because you are no longer working or going to school?
    -- Select One --YesNo

71. Would you like us to contact you and let you know if you qualify for a job search?
    -- Select One --YesNo

73. Is your change because you have a temporary break in your activity?
    -- Select One --YesNo

75. If yes, choose the reason for this break?
    -- Select One --Medical/Maternity LeaveSummer BreakSick ChildOther (please explain)

77. Please explain:

79. Is your child(ren) starting school?
    -- Select One --YesNo

81. If yes, enter the name(s) of the child(ren) starting school?

83. Enter the date your child(ren) will start school:

85. Are you wanting to transfer your child(ren) to another provider?
    -- Select One --YesNo

87. If yes, enter the name of the child(ren) you want to transfer:

89. Start date of when you want your child(ren) to start at the new center:

91. Name of the provider you are wanting to transfer to:

93. Have you verified that this provider has an opening for your child(ren)?
    -- Select One --YesNo

95. Is your parent fee paid in full to the provider you are currently using?
    -- Select One --YesNo

97. You wish to voluntarily withdraw your child from the CCS program?
    -- Select One --YesNo

99. If yes, please provide us the name of the child(ren) you want to withdraw:

101. Last day that child(ren) will need the child care services:

103. Please give us a brief explanation as to why you are choosing to voluntarily withdraw from services:

105. Would you like us to contact you regarding another matter?
     -- Select One --YesNo

107. So we can better assist you, please indicate the department that you may need to speak to:
     -- Select One --Client ServicesBilling ServicesProvider ServicesManagementDirectorWaitlist

109. Would you like us to contact you when change has been updated?*
     -- Select One --YESNO

     Please allow up to 24 hours for us to contact you

111. Best time to Contact you

113. Best number to Contact you at

115. Disclaimer

117. If there is a new person in the household, the following documents may be needed
     -a copy of verification of citizenship<BR>-a copy of the social security card* voluntary <BR>-Income documentation he/she is receiving.

     -a copy of verification of citizenship
     -a copy of the social security card* voluntary
     -Income documentation he/she is receiving.

119. If you have any other changes that need to be reported to CCS or you need immediate assistance, please give us a call at 325-795-4200.

121. Note: Please do not start your child(ren) at the new facility until you have heard from CCS. We must authorize child care at the new facility.

123. An Equal Opportunity Employer / Program Auxiliary aids and services are available upon request to individuals with disabilities.

Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit

* indicates a required field