School Readiness: Prequalification

1. Do you have children in your home younger than 13 years of age in need of child care? *

Yes

2. How many total adults and children live in your household? *

(Includes spouses, former spouses, persons related by blood or marriage, persons who are parents of a child in common regardless of whether they have been married, and other persons who are currently residing together in the same dwelling unit as if a family. (s.1002.81(9), F.S.))

3. Please select family size

3. Is your gross (before taxes) household annual income less than $ ##,###.00? *

Yes

If you receive relative caregiver benefits or TANF child only on behalf of the child(ren) for which you are seeking services, only the child's income is counted for the annual income listed above.

4. Is your gross (before taxes) household annual income less than $ ##,###.00? *

Yes

If you receive relative caregiver benefits or TANF child only on behalf of the child(ren) for which you are seeking services, only the child's income is counted for the annual income listed above.

4. Check all that apply: (Must check at least one) *

I am 65 years of age or older.

I am a single parent currently employed or attending school for at least 20 hours per week.

I am a two-parent family that works or attends school for a combined total of at least 40 hours per week.

I am a single parent who is exempt from work due to a disability.

I am a two-parent family wherein one or both parents are exempt from work due to a disability.

I have a child care authorization form (referral) from an authorized referring agency.

I receive Relative Caregiver benefits for the child(ren) requiring care.

I have a child that is aged 3 to kindergarten entry who has an IEP from the local school district.

None of the above apply.

5. I am currently receiving or have previously received school readiness services with another early learning coalition.

Yes

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