Illinois Central College Childcare Voucher Application

First Name

Last Name

Birthdate

Student ID Number

ICC Email Address

Mobile Phone

Please enter your current household situation.

Single

Married

With Partner

Prefer Not to Say

Have you applied for financial aid?

Yes

No

I need assistance completing FAFSA

Have you applied for Childcare Assistance Program (CCAP) funding?

Yes

No

I need assistance applying for CCAP

Were you approved for CCAP funding?

Yes

No

What is your co-pay through CCAP?

Do you have a childcare center selected?

Yes

No

I need assistance selecting a childcare center

Please enter the name, address and phone number of your selected childcare center.

Is your child currently attending this center? (Note: Childcare vouchers cannot be processed until attendance begins)

Yes

No

What type of care do you need?

Full Day Care (Over 5 hours per day)

Part Day Care (3-5 hours per day)

Hourly Care (1-2 hours per day)

Drop-In Care (sporadic, as needed basis)

Evening Care (5pm or after)

School aged care (after school, summers, days off)

Name of child #1 needing care.

Please enter date of birth for child #1.

Please provide relationship to the child #1.

Mother

Father

Legal Guardian

Do you have another child in need of care?

Yes

No

Name of child #2 needing care.

Please enter date of birth for child #2.

Please provide relationship to the child #2.

Mother

Father

Legal Guardian

Do you have another child in need of care?

Yes

No

Name of child #3 needing care.

Please enter date of birth for child #3.

Please provide relationship to the child #3.

Mother

Father

Legal Guardian

Do you have another child in need of care?

Yes

No

Name of child #4 needing care.

Please enter date of birth for child #4.

Please provide relationship to the child #4.

Mother

Father

Legal Guardian

Do you have another child in need of care?

Yes

No

Name of child #5 needing care.

Please enter date of birth for child #5

Please enter date of birth for child #5.

Please provide relationship to the child #5.

Mother

Father

Legal Guardian