PARKS, RECREATION AND COMMUNITY SERVICES DEPARTMENT
CHILDCARE SUBSIDY APPLICATION
Confidential Application • Please print clearly
Application #
________________
Date Received
________________
Program
________________
Staff Initials
________________
Section 1:
Applicant Information
Parent/Guardian Name
Home Address
Phone Number
Email Address
Child(ren) Information
Child Name Date of Birth Program Requested
Section 2:
Household & Income Information
Household Size: _________
Gross Monthly Household Income: __________________________
Section 3:
For information on required documents and category requirements please see pages 2-3 in the Culver City Parks, Recreation and Community Services Department Childcare Subsidy Handbook.
Income Verification Submitted:
☐ Pay Stubs ☐ Tax Return ☐ Benefits Letter ☐ Other ☐ CPS/Social Services Referral ☐ Child with Exceptional Needs
CERTIFICATION
I certify that the information provided is true and complete. I understand that eligibility may be verified and supporting documentation may be requested.
Applicant Signature Date
Printed Name
FOR PRCS DEPARTMENT USE ONLY
Eligible for Subsidized Childcare: ☐ Yes ☐ No ☐ Category 1: 100% ☐ Category 2: 50% ☐ Category 3: 15%
Reviewed By: _________________________________
Supervisor Approval: _________________________________________ Date of Approval: _______________ Follow Up Required: ☐ Yes ☐ No
Denied By: _________________________________
Reason Denied: _________________________________________________________________________________ ______________________________________________________________________________________________