Parent Application 0-3 years

Father's Place of Employment:

*If your child receives services from Birth to Three, please attach his/her current IFSP.

Father's Address:

How long would you need funding for? *

Does your child attend a daycare setting? If yes, direct your facility to apply by completing the application for facilities under APPLY FOR GRANT tab. *

Yes

No

Legal Guardian's Name:

Legal Guardian's County of Residence:

Father's Phone:

For any service selected above, please indicate the company providing the service(s):

Mother's Address: *

Legal Guardian's Address:

Explain your child’s challenges and why they need additional adult support, training or equipment, or care within your home: *

Child's Date of Birth: *

Mother's Name: *

Mother's County of Residence: *

Mother's Place of Employment: *

Mother's Email: *

Child's Address: *

Mother's Phone: *

Legal Guardian's Phone:

Legal Guardian's Place of Employment:

Father's Email:

Father's County of Residence:

Child's Name: *

How will this funding increase your ability to stay in the workforce? *

Does your child have a medical diagnosis or documented developmental delay? *

Yes

No

If yes, please list or explain:

When would you need funding to begin *

Legal Guardian's Email:

Father's Name: *

Individual Assistance Grant Application​FOr parents of children under 3 years old

Individual Assistance Grant Application
FOr parents of children under 3 years old