Forms

ELRC Region 5 is providing fillable PDF forms for families. These forms can be downloaded, filled out digitally, and sent back to the ELRC Region 5. NOTE: You must download the form prior to filling it out.

For additional questions, please contact ELRC Region 5 at 412.350.3577 or email us at elrc5@alleghenycounty.us.

Low-Income Forms

• Child Care Works (CCW) application

  • Español

• Authorization for Release of Information    

  • Español

• HIPPA Notice Signature Page

• Employment Verification

  • Español

• Self Employment Verification

  • Español

• Child Disability Verification

• Anticipated Self-Employment Income and Schedule

• Cash Verification

• Self Declaration Form

• Child Care Declaration Form

• Rights and Responsibilities Form- Low-Income/Head-Start

• Medical Assessment Form

• Homeless Verification

• Class/Training Schedule Verification

• Education Schedule Verification

• Parent/Caretaker and Related Provider Attestation

• Continuity of Care Application