Requirement

State regulations require a formal application & certification to receive child development services. This application, also known as the Confidential Application for Child Development Services and Certification of Eligibility, must be completed by an agency representative in consultation with the family. The agency must verify and certify family eligibility prior to beginning services.

Regulations/Reference

EED Program Instrument: I. Family Files
Title 5: 17753, 17757

Monitoring Review Evidence

• Application for Services & Information Verification

• Records of Eligibility, Residency & Family Size

• Records of Verification of Eligibility Information

• Written Materials for Parents

Who Completes the Application

Completed by staff in consultation with parent!

According to the regulations, the contractor must designate a staff person authorized to certify family or child eligibility prior to initial enrollment & at the time of recertification.

The authorized representative must certify each family’s or child's eligibility for preschool services after reviewing the completed application for services & documentation contained in the family data file. 

What this might look like in a program:

• Enrollment Specialist reviews documentation to determine if it meets eligibility requirements & applications are completed with the parent/guardian through an interview process.

When is the Application Completed

The Application for Services must be completed prior to initial enrollment & at the time of recertification.

24-month eligibility starts on the date the contractor’s authorized representative signed the application for services certifying that eligibility criteria has been met.

In the event that the eligibility period ends before the end of a program year, extend until the kindergarten start date, as long as child is age-eligible.

NOTE: If multiple children are in the family at the time of enrollment or siblings are enrolled during the certification period; then the application for the child that is certified to receive services first is used to determine when eligibility starts.

Step 1: Add specific dates to notification as follows:

1. Date agency representative approved prior application

2. Issue date: 23 months after date application was signed

3. Recertification appointment date: Date must fall
   after 24 months plus 1 day has passed since date application was signed

4. Final recertification process date: 50 calendar
   days from the 24 day plus 1 date after application was signed

Step 2: Add applicable forms to recertification packet, such as an Employment Verification if parent is working

Step 3: Email packet or print for pick-up. Sample email language:

Hello, this is Kristie with Monarch Link. It’s time to recertify your child’s services. Attached is your recertification packet that includes instructions on what is needed to continue receiving services. 

Please bring ALL completed documents to your recertification appointment scheduled for July 19 at 9am.

We understand that there are many forms that need completed and documents that will need to be gathered. If you have any questions along the way please contact our office by email or telephone (209) 555-1234.

How is the Application Completed

REMINDER: How you capture a family on the Application for Services, is how they are certified for the next 24 months, so “get it right from the get-go”

Header

Agency Name: Name of the agency providing or funding child care services

Family Identification/Case No: The unique Family Identification Number (FIN) or Family Case Number (FCN) assigned to the family

Initial Subsidized Service Date: The earliest month & year child(ren) first started receiving subsidized child care services from your agency. 

Note: If there is a break of 3 months or more, enter the month child care resumed. If there is a break of less than 3 months (vacation, for example), enter the original date assistance began, not the date it resumed.

Type of Application: Check Initial if this is the first application. Check Recertification if this is the second or later application.

Pilot Program: Select “yes” if this is a pilot program or “no” of this is not.

Parent/Guardian preference of receiving official communication: Select the mail or email box based on the parent’s communication preference. 

Section I: Family Identification

If family size includes more than two adults, complete Section I of a second application & attach it to the complete application.

Single parent/caretaker: If the child lives with only one parent or caretaker who is legally/financially responsible for the child, check the box within the Single parent/caretaker space.

Parent/Guardian A: Contact Information.  For the first adult living in the same household as the child(ren), complete all items in Section I, including address information.

Parent/Guardian B: Contact Information. If a second parent or caretaker lives in the same household as the child & is included in the calculation of family size, complete section I B.  

FIPS Code. The FIPS code consists of a state code, which is a two-digit number, & a county code, which is a three-digit number.  See the “FIPS Codes” section on page 3 of the application instructions to determine the FIPS Code that identifies the state & county where the parent/caretaker lives.

Section II: Family Eligibility

Eligibility is based on either child or family eligibility. For a family to receive services, parent’s must provide documentation of eligibility in 1 or more of these categories.

Family eligibility status.  Check all eligibility categories for which the family qualifies. 

Note: If the family has more than one child and any of the children qualify for a child specific eligibility category, such as child has exceptional needs, more than one eligibility category must be checked. 

Section III. Reason for Needing Services

For full-day programs, all parents counted in the family must have a verifiable and documented need for services.

For each parent, guardian or other adult included in the family size record with an “A” or “B” all of the reasons for needing services and attach the appropriate documentation.

Section IV. Employment /Vocational Training /Education Program Information

For full-day programs, if applicable, for each parent or guardian enter:

• The name, address, and phone number of the employer or the institution of training or education

• Record the beginning and ending hours for each day that the parent or guardian is employed, or is in an education or training program.

Section V: Family Adjusted Gross Monthly Income & Size

Family monthly income.  Enter the family’s total adjusted gross monthly income from all sources. All income must be verified.

NOTE: In the event that zero income is declared, enter zero within this section, and include in the family data file a statement from the parent that they receive 0 income.

Family Size.  Enter the total family size.

• For biological or adoptive parents, family size includes all parents listed within Section 1 and all children listed within Section 5 and 7 of the application for services.

• For foster parents or guardians, family size includes all children and their related siblings.

Section VI: Data on Children Served in the Program

Complete Section 6 only for children served by agency. If needed, use a second application to record more children.

Child Information: Enter the child’s legal name, birthdate and IEP/IFSP status.

Child Hours of Care (School): Indicate the amount of certified care during the preschool session

Child hours of Care (Vacation): Indicate the amount of time needed during vacations.

NOTE: For preschool-age children, leave this box blank, unless outside school or services are being used in combination with preschool hours.

Section VII: Data on Children Not Served in the Program

Complete Section 7 for all children included in the family size that are under 18, for whom the parent is responsible and not receiving services in the program.

These rows include the full name of the child and their birthdate.

Section VIII: Certification & Signature of Parent/Guardian

Read and explain the conditions of eligibility to the parent/guardian & make sure they understand them before signing the application. Remember:

• Do not rush

• Review each section

• Review supporting documentation

• Check the facts

• Ensure application aligns with supporting documentation.

Before the agency representative signs the application, The parent or guardian completing the application must sign and date the form to declare under penalty of perjury that all information is true and correct to the best of their knowledge. At least one parent signature is required on the application. 

Section IX. For Office Use Only

The agency representative must complete the items in this section. The certification is not complete until the application is signed & dated by the agency representative. 

The signature of a second agency representative, such as a supervisor is an optional field and is not required.

Date Notice of Action Sent/Provided: Indicate the date the Notice of Action was sent or provided to the parent.

First Date of Subsidized Service: The first date of subsidized services is the child’s first day of care.

Last Date of Enrollment: The last date of enrollment is left blank until the family leaves services.

In addition to the Application for Services form, note that there is an Appendix form. The Appendix form is used to gather additional required information needed to submit data to the California Preschool Data Collection System or CDMIS.

NOTE: Contractors may develop their own form or forms as long as the required data elements are incorporated.

Section 1. Additional Child Information:

• Enter the child’s legal name, country, state, and city of birth.

• Child’s Ethnicity: A mark in the “Yes” box would indicate that a child’s parent has identified the child as having an ethnicity of Hispanic. A mark in the “No” box would indicate that he or she does not. 

• Child’s Race: Mark all that apply.

• Child’s Gender: Mark the appropriate box for the child’s gender.

  NOTE: Gender is a child’s actual sex or perceived sex and includes a person's perceived identity, appearance, or behavior, whether that identity, appearance, or behavior is different from that traditionally associated with a person's sex at birth. 

• CalWORKs Recipient: Mark the appropriate box for whether the child or family is a CalWORKs Recipient. 

Section 2. Additional Parent/Guardian Information:

• Parent/Guardian Highest Education: For the parent or parents, mark the highest educational level attained. Mark "Decline to State” if they decline to state their highest education completed. If the child is in foster care or in an informal custody situation without a legal parent or guardian, please write "Decline to State”. 

  NOTE: If the child is in foster care or in an informal custody situation without a legal parent or guardian, the child would be the head of household, and the child’s information should be written and reported in the Head-of-Household name section, followed by Decline to State

Section 3. Mailing Address:

• If the family has a mailing address that is different than their home address listed on the application for services, record this here.

Section 4. Family Language Instrument:

• If the family declines to answer any of the Family Language Instrument questions, the contractor may write “Undetermined” within the response field.

• If the family declines to state responses for all Family Language Instrument questions, the contractor may write “Family Opts Out” for each question in the instrument. 

ORIGINAL in Family Data File

Once you have completed the family’s certification:

• File the ORIGINAL application in the family data file, followed by the supporting documentation

• If the family has a new or updated certification, add it to the family file. DO NOT remove the earlier applications

• Issue a Notice of Action approving or denying services within 30 days of parent signature on the application
  
  

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