Working Parent Application Working Parent Application Process Date MM slash DD slash YYYY Please Select the Preferred Location for Your Child* Swissvale (2538 Woodstock Ave, Pittsburgh, PA 15218) North Side (2615 Norwood Ave, Pittsburgh, PA 15214) Parent Applicant's Name* Second Parent's Name (not required) Parent Applicant's Address with Zip Code* Parent Applicant's Phone Number* Parent Applicant's Email Address* Parent Applicant's Date of Birth* Parent Applicant's Marital Status* Married Unmarried Divorced Separated Widowed Child's Medical Insurance (List Provider)* Parent Applicant's Living Arrangement* Parents Relative Independent Other Number of People Living in Your Household Means of Support for Parent Applicant* TANF (Cash Assistance, SNAP) Parents Employment Other Name, Address and Phone Number of Parent Applicant's Employer* Parent Applicant's Current Annual Income* Name of School Attending* School Last Attended Last Grade Completed* List any Degrees, Certificates, or Diplomas you have received and from where.* Names, relationship to Parent Applicant's, and projected annual income of all adults in child's household* Name, birthdate, and gender of all child(ren).* How many children do you plan to enroll in Angels' Place?* If one parent has custody, as determined by court, does the non-custodial parent have permissions to pick up the child? What type of alternative child care has your child experienced to date(e.g., private caregiver, day care home, group day care, preschool, etc.)? Please give details.* How has your child reacted to this care?* How did you hear about Angels' Place, Inc.?* Special Circumstances or Additional Information CAPTCHA
