Arkansas Better Chance Program
fY
Divili:n of Child
Early Child
rurd
P.O. Box 7437, Slot 5-160
tittle Rock, Arkansos
Care and
72203
Educatkrn
Eligibility Application
I
!
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**-,...*-|
iEnrolling
i
Ngency
i
,Enrolling Site
Primary Caregiver General lnformation
iM.lnitial
iFirst Name
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iGender
mm-dd-yyyy
Male
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Female
mm-dd-yyyy
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tt
!*Birth Date
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Yes
iranr *
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No
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I
Stamp/ SNAP
i*other
:*Language
!
iLanguage
i*Race
{'Ethnicity
:
:1 Hispani.
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rT yes,
cuban
'
!r Yes, Mexican, Mexican
American,Chicano
,
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' .. Yes, Other Spanish, Hispanic,
Lattno
T yes, puerto Rican
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,
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^- --:^-- ,-ri^lndian
American
YesF
or I-
I Chinese
r lmmigrant
F
' Migrant
T Other
Ir_ samoan
'
r
r
T
tr
'
Multi-Racial
Other Asian
unknown
Bachelor or Advanced Degree
college degree or
training
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lr
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certificate
lschool
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lr'-
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lr
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GED
Grade 10
Other, Pacific lslander
Vietnamese
Farmer
Full-time & training
Employed full-time
lStatus
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Homemaker
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ir
lr
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Jo b
tra ining/school (part-time)
Migrant Farm worker
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Grade 11
:
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iEmptoyment
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Native Hawaiian
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Korean
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in
lEducation Level
r
r
r
r
Japanese
Guaanian or Chamorro
:
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T
Filipino
Black or African American
White
iri.
r'
Astan lndtan
Alaska Native
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Part-time & ffaining
!
Grade 12
lit
Employed part-time
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ABC Form # 003
No
(Eff. Date
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Grade 9 or less
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High SchoolGraduate
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No High school
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or in school
Employed seasonal
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Some College/
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Seasonal Farrn worker
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focationa l/Associates Degree
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ir
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Self Employed
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Some High School
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Job training
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Retired or disabled
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Unemployed
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unkno*n
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Unknown
-. .- ....-*-. -*i..-._.-
iEmployer/ School name
iPhone(home)
iPhone(work)
lHome Address
tCitV
lState
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-.j
iNAME
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f
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List name and
relationship to
the child of all
family members
in the household.
f
Singre
Divorced
widowed
separated
other
Aetna Global
AHA Care
Ambetter
iDisabled
Yes
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irvr"aicrl
No
ilnsurance
(for Childlj
ir
,
Yes
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ARKids
ruo PRecifv:
lst
ARKids A
i
ARKids B
blue advantage
Blue Cross Blue
CareFirst
ABC Form # 003
(Eff. Date oTl0LlLsl
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,
:
Homeless
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*Current
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Housing
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mm-dd-yyyy
!*Previous
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lHousing
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lXas this
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family moved in the tast 24 months?
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Yes'
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No
iPrimary Caregiver Comment
i$_lr*,_
Male
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l
Female
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,*Ethnicity
rril nirprni.
,,
I Yes, Cuban
lru
Y"r, Mexican, Mexican
i
Chicano
il""
ir
i'ir
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ir
:'
Latino
in Yes, Puerto Rican
ABC Form # 003
Chinese
!
lmmigrant
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i' Yes, other Spanish, l'
r!
rHispanic,
flmerican,
t*
American lndian orAlaska Native
j'if
ir
uigrant
ott
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Samoan
r
r
r
tr-
'
Asian lndian
f,
Black or African American
r
Japanese r
Guaanian or Chamorro
Multi-Racial i
Native Hawaiian
Firipino
r other Asian F
r-' unknown r
Korean
Other, Pacific lslander
Vietnamese
(Eff. Date
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i
Bachelor or Advanced Degree
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ir
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college degree or training school
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icertificate
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ir
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ir
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Ir
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Full-time & training
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!'
ir
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ir
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GED
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Grade 10
Employed full-time
Homemaker
Jobtraining/school(part-time)
Migrant Farm worker
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Grade 11
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lEducation Level
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Grade 12
Grade 9 or less
:
ir
xign SchoolGraduate
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Job training or in school
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tuo High School
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Employed seasonal
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Some College/Vocational/Associates
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Seasonal Farm worker
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IT
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ir
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!
ir
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iDegree
in
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som" High School
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Self Employed
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Unemployed
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unknown
lri
:
Unknown
rEmployer/ School name
iPhone(mobile)
,
iPhone(workl
I
lHome Address
Same as Primary Caregiver's
iworkzip
1i
ABC Form # 003
(Eff. Date
i
oTl0].ltsl
Aetna Global
fits
AHA Care
Ambetter
ARKids
t
lr
lr
lst
ARKids A
ARKids
B
i
Blue Cross Blue
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lr
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r Yesf No
loisabled
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inneUical
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lnsurance
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tx
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Yes
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!
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predfv
CareFirst
No
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l
blue advantage
Cigna
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i
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Health Network
I
I
I
Louisiana
Medicaid
Medicare
Private Health
QualChoice
TriCare
UnitedHealthcare
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t
Fecondary Caregiver
I
lComment
Fields marked with (*) are required for PIR reBort
ABC Form
f
003
(Eff. Date
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