Child Care Benefit Form - Ohio
SECTION V CHILDREN WHO NEED CHILD CARE (Complete one page for EACH child w ho needs child care)
1. Child’s Name (First , Middle, Last)
Race
(mark "Y" or "N" for EACH group)
Y N
African Americ an/Black
Alaskan Native/Ameri can Indian
Asian
Native Hawaiian/P acific Is l ander
White
Child’s Mother’s Maiden Name
*Current grade level of child: *If child is attending grade kindergarten or
above, this sect i on must be comp let ed.
School year start date : and end date:
Ethnicity/Hispanic
Y N
Hours of school: from to = (hrs.)
Is child entering kindergarten?
Yes No Begin date:
Name of school
School address
Does child have any special needs? Yes No If yes, please descri be:
Does the child require protective child care? Yes No
If yes, is there a current case plan for the caretaker with whom the child resides?
Yes No
Is the child enrolled in a federally funded head start program?
Yes No
Is this child a United States citizen or a
qualified alien? Yes No
You must provide verific at i on in order to
receive child care.
City of Birth:
Indicate below your choice of provider(s) for each day and the hours of care requested. If you are using only one provider for all
requested times, you may indicate the name of the provider one time. You must clearly show which provider you are requesting for
each day and time.
Days and Times of Care
Name and Address of Provider for
Child Named Above
Sunday F rom to
From to
Monday From to
From to
Tuesday From to
From to
Wednesday From to
From to
Thursday From to
From to
Friday From to
From to
Saturday From to
From to
JFS 01138 (Rev. 2/2015) Page 6 of 10
Page 6/12
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Child Care Benefit Form - Ohio PDF
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