HHSA - DSS - CCP8 - Stage One Childcare Authorization

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALWORKS STAGE ONE CHILD CARE AUTHORIZATION FORM
NOTICE: You are authorized for CalWORKs Stage One Child Care. Please complete and return this form when you have found someone to take care of your child(ren).

CHILD CARE AUTHORIZATION

You have been authorized for:
Full-time child care
Part-time child care
Child Care Authorization Start Date

MonthDayYear
mm/dd/yyyy
End Date

MonthDayYear
mm/dd/yyyy
CHILD CARE PROVIDER INFORMATION

Please complete the following information about your child care provider:
Child Care Provider Name
Telephone

Area CodePhone Number
Address
My child will start care on:

MonthDayYear
mm/dd/yyyy
My child care provider is:

LicensedLicense-exempt
If your child care provider is license-exempt, they may have to go through the TrustLine finger printing and background check process. Please see TrustLine section below.
Check this box if you have more than one child care provider, then please complete the following information for your additional provider:
Child Care Provider Name:
Telephone:

Area CodePhone Number
Address
My child will start care on:

MonthDayYear
mm/dd/yyyy
My child care provider is:

LicensedLicense-exempt
If your child care provider is license-exempt, they may have to go through the TrustLine finger printing and background check process. Please see TrustLine section below.