Eligibility Questionnaire for Subsidized Child Care Services

This Eligibility Questionnaire (EQ) provides us with your basic information so that you can be placed on Children’s Home Society of California’s (CHS) Child Care Eligibility List (CCEL) to wait for available funding for child care. This is not an application for any particular program. It is very important that you provide all information requested so that your family can be placed on the list for subsidized services. If you have any questions about how to complete this form, please call our office.

*If you are currently receiving Medi-Cal, CalFresh, California Food Assistance Program, California Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Federal Food Distribution Program on Indian Reservations, Head Start, or Early Head Start benefits, only enter the income amount that you entered on your application for services for that program. Do not enter additional income.