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Online Application Fields

You will have complete control over the fields that ChildPlus includes on your agency's Online Application. Based on the fields you choose, you can make your agency's Online Application as brief or as comprehensive as you'd like. Here's a complete list of all of the fields that you'll be able include on your Online Application. If the field has an asterisk next to it, the parent will be required to complete it in order to submit their child's application. Two asterisks means that you may need to customize Dropdown Choices for this field if you are using Spanish Applications.

Fields Related to Children:

First Name*

Middle Name

Last Name*

Suffix

Nickname

Birthday*

Gender

SSNSocial Security Number

Race

Hispanic/Latino

English Proficiency

Other Language**

Other Language Proficiency

Primary Health CoverageThis field is used to calculate health insurance questions on the PIR. Select Medicaid if the child has been officially certified as eligible for Medicaid paid services; select CHIP if the child has been officially certified as eligible to receive services covered by the State Children's Health Insurance Program; select Private Health Insurance if the child is covered under health insurance held by his/her parents or guardians; select Other if the child has health benefits through the military or another organized source of health care coverage. If you select Other, use the Other Coverage box for notes and comments about the child's health coverage.

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical HomeAn ongoing source of continuous, accessible health care.

Dental Coverage

Dental Coverage Number

Dentist/Dental HomeAn ongoing source of continuous, accessible dental care provided by a dentist.

Does your child have a disability?

Application Notes

Fields Related to the Family's Address:

Is your family experiencing homelessness?*

Living Address*

Mailing Address same as Living Address

Mailing Address

Fields Related to Primary and/or Secondary Adults:

First Name*

Middle Name

Last Name*

Suffix

Nickname

Birthday*

Gender

SSN

Race

Hispanic/Latino

English Proficiency

Other Language**

Other Language Proficiency

Highest Grade Completed**

Employment Status**

Relationship to Participants**

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Email Address

Fields Related to the Family:

Parental Status

Primary Language at Home **

Number in Household

Number in Family

Gross Annual Income

Phone Numbers

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANFTemporary Assistance for Needy Families) program?

Is your family receiving Supplemental Security Income (SSISupplemental Security Income)?

Is your family receiving services from WICSpecial Supplemental Nutrition Program for Women, Infants, and Children?

WIC ID

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

Related Topics

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	Getting Started		PIR Resources		Get Ready for Next Year
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	ChildPlus e-books		PIR Reports		Create New Program Term
	Blank Paper Applications		ChildPlus PIR User Guide		Rollover - PNPT
	Frequently Asked Questions		2020-2021 PIR (OHS)		Closeout - PNPT
	Common Monthly Reports		PIR Frequently Asked Questions		Purge Previous Program Terms
	Teaching Strategies GOLD
	Contact Us		Your opinion counts. Vote today!		ChildPlus Help Home Page

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