First Name *

Last Name *

Email *

Agency Name (Your Employer) *

Your agency must be a member of the Indiana Association for Home and Hospiace Care (IAHHC). Go to https://members.iahhc.org/member-directory to see if your employer is a member. 

Agency City *

Employment Start Date *

You must be employed for a minimum of 60 days at your agency to be eligible

Dependent Name *

If you have more than 1 dependent in childcare, please submit a new application for each dependent. 

Childcare Agency Name *

Childcare providers must maintain status as a licensed, regulated, or registered child care provider and remain in good standing with the Indiana Office of Early Childhood and Out of School Learning. (If you are unsure if you're child care provider is licensed, regulated, or a registered childcare provider, please submit an application and we will verify that your childcare provider is eligible).

Childcare Agency Address *

Childcare Agency City *

Childcare Phone Number *

Childcare Agency Email

My child/dependent is enrolled in:

Full Time Childcare

Part Time Childcare

After School Childcare

Summer Childcare

Is your child currently enrolled and attending at this location? *

Yes

No

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