Form Request – JALC CCR&R

Online form request

Welcome to CCR&R at John A Logan College’s On-Line Form Request for the IDHS Child Care Assistance Program. All forms requested will be mailed to the address you list within 1-3 business days. If you do not receive the form, please call our office at 1-800-548-5563.

First Name

Last Name

Last Four Digits of Social Security #

Phone Number

Email address

If you are receiving child care assistance currently, who is your provider?

Which form are you requesting be sent to you? Forms (other than an application) can only be sent to the parent/guardian on the case:

How would you like to receive the forms?

What is the street address that you want the form sent to? (Must be address of the parent unless you are requesting an application

How did you hear about our program? Family? Friend? Flyer? Internet? Provider? Other- please specify.

Comment

Accessibility Adjustments

Powered by OneTap

Select your accessibility profile

Vision Impaired Mode

Enhances website's visuals

Seizure Safe Profile

Clear flashes & reduces color

ADHD Friendly Mode

Focused browsing, distraction-free

Blindness Mode

Reduces distractions, improves focus

Epilepsy Safe Mode

Dims colors and stops blinking

Content Modules

Font Size

Default

Line Height

Default

Color Modules

Orientation Modules