Application for Services Contents

18083

The application for services shall contain the following information:

(a) The parent's(s') full name(s), mailing address(es), telephone number(s), and email address(es), if available;

(b) The names and birth dates of all children under the age of 18 years in the family, as defined in section 18078, whether or not they are served by the program;

(c) The maximum number of hours of care needed each day or week for each child;

(d) The basis of the family's eligibility as specified in Education Code section 8263(a)(1)(A), which may be either:

(1) The parent is receiving CalWORKs cash aid;

(2) The family is income eligible;

(3) The family is experiencing homelessness;

(4) The child is receiving child protective services; or

(5) The child is identified as being abused, neglected or exploited or at risk thereof.

(e) The reason(s) for needing services as specified in Education Code section 8263(a)(1)(B) which is (are):

(1) The child is receiving child protective services;

(2) The child is identified as being abused, neglected or exploited or at risk thereof;

(3) The family is experiencing homelessness;

(4) The parent is employed;

(5) The parent is seeking employment;

(6) The parent is enrolled in vocational training;

(7) The parent is enrolled in educational programs;

(8) The parent is incapacitated; or

(9) The parent is seeking permanent housing for family stability.

(f) Employment, vocational training, or educational program information for the parent(s) shall include:

(1) Name and phone number of the employer or contact person;

(2) Name and address of the business, vocational training, or educational program; and

(3) Days and hours of employment, enrollment in vocational training, or an educational program, as applicable.

(g) Family size and family's adjusted monthly income, if applicable.

(h) The parent's signature signed under penalty of perjury and date of the signature.

(i) The signature of the contractor's authorized representative certifying that the family and/or child meets the criteria for receipt of services.

NOTE: Authority cited: Sections 8261 and 8263, Education Code. Reference: Sections 8261 and 8263, Education Code.