Seton Hill Child Care Services Daycare Day Care Pennsylvania PA Greensburg Jeannette Irwin Latrobe New Kensington 15601 15666 15650 15644 15068 westmoreland county 724-836-0099 infant toddler preschool pre-school school age k-care head start early head start pre-k counts foster care tanf ssi summer
Required Fields (*)

Select Center(s) of Interest:
* Child's Name:
* Date of Birth:
       
Child's Gender: * Total Number of Children in Household: 
Parent E-mail: *Total Number of Adults in Household: 

* Mother/Guardian Name: Date of Birth:
* Address:  
*City: *Zip code:
* Home Number: Cell Number:
Employer Name: Employer Phone Number:

* Father/Guardian Name: Date of Birth:
* Address:  
City: Zip code:
* Home Number: Cell Number:
Employer Name: Employer Phone Number:

Other Members of the Household
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:

Are you receiving CCIS Funding?
What school district does your family currently reside?
Is there a Court Order limiting or restricting custody and/or access to the child(ren)?


If you would like to be considered for funding assistance, please complete the following information as accurately as possible:

(The information given below is confidential. Information will be used to determine eligibility for programs. You are not legally required to provide this information.)
HOUSEHOLD INCOME:
*Employment (combined gross monthly income):
* Social Security (monthly payment):
* Child Support (monthly payment):
* Unemployment Benefits (monthly payment):
* Alimony/Spousal Support (monthly payment):
* Other Income (monthly payment):
* TOTAL GROSS MONTHLY INCOME:
(From sources checked above)
* GROSS FAMILY INCOME:
(From the past 12 months)


* IF YOU ARE APPLYING FOR HEAD START OR EARLY HEAD START, PROOF OF INCOME (12 MONTHS PRIOR TO APPLICATION DATE), PROOF OF CASH ASSISTANCE, SSI DOCUMENTATION OR FOSTER PLACEMENT LETTER MUST BE SUBMITTED ALONG WITH THE APPLICATION TO BE CONSIDERED FOR THE PROGRAM (ANY AND ALL DOCUMENTS SENT WILL BE KEPT CONFIDENTIAL)*

Upload proof of income:


*Does anyone in your household currently receive cash benefits?
*Does anyone in your household receive SSI benefits?
*Is either parent/guardian currently working?
*Is either parent/guardian currently training or in school?
*Does your child have a disability?
If yes, explain:
*Does anyone in your household have a disability?
If yes, explain:

Please indicate any issue(s) that has affected or is now affecting the family or family members (check all that apply):

















-If there is a Court Order, please provide a certified copy of the order. Court Order must be updated as appropriate. I certify that the information I have provided is true and accurate to the best of my knowledge.

I give my permission for the above information to be obtained and/or released to most appropriately funded programs for my child.
* Parent Signature (Please type full name) Date:  11/23/2017
I was referred to Seton Hill Child Services, Inc. by: