Child Care Resource and Referral CCAP Request Form

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Welcome to CCR&R at John A Logan College’s On-Line Form Request for the IDHS Child Care Assistance Program. All forms requested will be mailed to the address you list within 1-3 business days. If you do not receive the form, please call our office at 1-800-548-5563.

Which form are you requesting be sent to you? Forms (other than an application) can only be sent to the parent/guardian on the case.:

Application (for applicants who have not had an active case within the last 30 days) Application - new baby (when adding a new baby to your case) Redetermination (must be completed at the end of your eligibility period to continue your case or if your information changes during your eligibility period- i.e. job, marital status, family size, etc.) Provider Change (if you are changing or adding a child care provider)

What is the name of the parent?:

Last four digits of your case number? This is for the parent or guardian of the case.:

If you have already chosen someone to care for your child, is it a friend neighbor or relative?:

Yes No

What is the street address that you want the form sent to? (Must be address of the parent unless you are requesting an application.):

What city would you like the form sent to?:

What is the Zip code to the address?:

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