Service Industry Recovery (SIR) Child Care Enrollment Form

Complete the following information for the parent or caregiver who is a Service Industry Worker in need of child care for their child(ren) in order to work.

Parent/Guardian Name*
Are you a current Child Care Services customer? Please place a checkmark by your response below:*
Date of Birth*
Physical Address*
Mailing Address (if different)

After you submit this form, you will be contacted by Workforce Solutions staff and asked to provide additional  personal information over the phone which will include which child care provider you have chosen.


Complete the section below with information for each household member. Household members consist of spouse/partner and dependents only. (Attach an additional sheet if needed.)

Name*
Date of Birth*
Gender*
Hispanic/Latino*
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.
Name*
Date of Birth*
Gender*
Hispanic/Latino
Child Care Needed*
Proof of citizenship/legal status*
No File Chosen
File uploads may not work on some mobile devices.

Based on family size*, is your income** at or below these annual or monthly limits of State Median Income (SMI) in the chart below?
    

               Family Size                  Annual Household Income               Monthly Household Income

                                                              at or below 75% SMI                                 at or below 75% SMI

                        2                                                  $43,549                                                        $3,629

                        3                                                  $53,796                                                        $4,483

                        4                                                  $64,043                                                        $5,337

                        5                                                  $74,290                                                        $6,191

                        6                                                  $84,537                                                        $7,045

                        7                                                  $86,458                                                        $7,205

                        8                                                  $88,380                                                        $7,365

                        9                                                  $90,301                                                        $7,525

                       10                                                 $92,222                                                        $7,685

If your family income is above the 75% SMI limit, based on the previous chart, you do not qualify for SIR child care and cannot apply for this program.

* Family size consists of parents, those in the home that can be claimed as dependents on a federal tax return, or a minor who is the responsibility of the parent/applicant.

**Income does not include federal or state assistance or child support.  A family’s monthly income is the gross income before adjustments are made for taxes, which can also be referred to as gross earnings or gross pay.

The Texas Workforce Commission in partnership with 28 local workforce development boards forms Texas Workforce Solutions Equal Opportunity Employer/Program Auxiliary Aids and Services are available upon request to individuals with disabilities. Relay  TX: 711 or  1-800-735-2988 (Voice) or 1-800-735-2989 (TDD).   La Texas Workforce Commission esta en colaboración con 28 juntas locales de desarrollo laboral forman La Texas Workforce Solutions. Es un empleador que promueve la igualdad de oportunidades. Relay TX: 711 o 1-800-735-2988 (Voice) o 1-800-735-2989 (TDD)   Documentos y formularios estan disponibles en Español a peticion.  Favor de llamar al 1-877-223-0404 ext 4013.

Service Industry Child Care Enrollment Application 8.2021


Service Industry Recovery (SIR) Child Care Enrollment Form

Employer Information

Self

Spouse/Partner

Address*
Spouse/Partner Address

Which occupation qualifies you as working in the Service Industry Sector? Please place a checkmark by the occupation category that best describes you (only one parent is required to be working in Service Industry Sector):

Occupation*

Please submit proof of employment in the qualifying occupation. Examples of acceptable documentation are:

Proof of Employment*

Click here to download the Employment Verification Form.

• Current paystub*
No File Chosen
File uploads may not work on some mobile devices.
• Employment verification form *
No File Chosen
File uploads may not work on some mobile devices.
• Letter of employment *
No File Chosen
File uploads may not work on some mobile devices.
By signing this document, you agree to the following statements:

Click here to obtain a complete CCS Provider list. And then fill out the information about your selected Provider in the spaces below. Child Care Services contracts with National Accredited Providers and Texas Rising Star. We ask that you call and / or visit your selected Provider so that you can verify that space is available for your child. If no space is available, you will need to select another Provider.  This information will be used if you determined eligible to receive child care services.

Provider Address
Use your mouse or finger to draw your signature above
Date*

Documents required to be submitted prior to eligibility determination for SIR child care:

         •   Proof of employment in a qualifying occupation.

         •   Proof of citizenship/legal immigration status for children needing care.

         •   Completed and signed SIR Child Care Enrollment Form (this application).


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