Laurel Highlands Workforce & Opportunity Center

Assistance Application


First Name

Last Name:

Address:

City:

State

Zip Code:

Home Phone: (Numbers only, no dashes)

Cell Phone: (Numbers only, no dashes)

Email Address 1:

Which assistance are you applying for? (Check all that apply)
Childcare Transportation Both
Annual Income

Source of Income

Are you on any public assistance programs?
Yes No
If so which ones?�
SNAP (Food stamps) TANF (Cash Assistance) Medicaid (Health Insurance)
For transportation assistance please answer the following questions.
Are you a licensed driver?�
Yes No
Do you have a reliable vehicle?�
YES NO
If you are licensed and have a reliable vehicle is the cost of fuel hindering you from driving yourself to school?
YES NO
Total Mileage (roundtrip from home school)

For childcare assistance please answer the following questions.
Is your child(ren) currently enrolled in a daycare?�
YES NO
If so, where are they enrolled?

Please answer the following questions for all children in need of childcare: Childs Name Age DOB

Are any of your children of school age and requiring before and after care or summer care only?�
YES NO

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