Seeking Employment Plan

I, ___________________________________, declare that I am currently seeking employment and in order to

(Print Parent Name) attain employment I will need child care services for my child(ren). I
understand that I am entitled to only a total of 12 months within my 24 month eligibility to seek employment, with
written authorization from my Family Services Specialist.

• What is your plan to secure, change or increase employment (how & where will you look for work? Please
be as detailed as possible)? _________________________________________________________________
___________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________

• No more than 32.5 hours can be authorized weekly, Monday-Friday. A child care schedule must be approved by
your Family Services Specialist. Hours can be set or varied. What hours do you feel will be needed for seeking
employment? Select one below:

* Set Schedule:

Day of the Week Start time End time

Monday
Tuesday
Wednesday
Thursday
Friday

* Varied Schedule:

Range of hours: _______________ to _______________ _______________

Earliest start time Latest end time Max. Hours per week

I hereby certify under penalty of perjury that the above information is true and accurate. I understand that I must notify
my Family Services Specialist immediately if I need a change in my child care schedule due to having another certified
need such as working, vocational training, incapacity, or seeking permanent housing, and that retroactive changes to my
authorization will not be made.

_________________________________ __________________________________ ________________

Print Name Parent Signature Date

Rev. 5/30/17