Form 1 Childcare Application w Privacy Statement

AMERICORPS CHILD CARE PROVIDER INFORMATION AND REGISTRATION FORM

PLEASE PRINT CLEARLY * TO BE COMPLETED BY CHILD CARE PROVIDER ONLY*

Provider’s Name:                Date of Birth:    _____/_____/_____

(As it will appear on checks)

Provider’s Mailing Address:   

___________________________________________________                  __________________________                          __________________                                ____________                                                                                    Street Address                                                          City                            State                                  Zip Code

Address where care is to be provided:

___________________________________________________      ____________________________ ________________                            ____________

                                            Street Address                          City                            State                                    Zip Code

In which county is care provided?          _______________________________              Provider’s telephone number    (_______)________-_________

AmeriCorps Member’s Name: ____________________________________________    NSPID #: ___________________

Date Care Begins: _____/_____/_____        Date Care Ended (if applicable):    _____/_____/_____           

NAMES OF CHILDREN TO BE CARED FOR THROUGH AMERICORPS CHILD CARE

Name of Member’s Child(ren) In Your Care		SSN (must be filled in)		Date of Birth		Gender (M/F)		Relationship to Provider
1.		-                    -
2.	-                    -
3.		-                    -
4.		-                    -

Name of    Member’s Child(ren) In Your Care

Period of Care (Check all that apply)

Hours Children are in Care

SUN

MON

TUE

WED

THU

FRI

SAT

From

To

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To be completed by Family Day Care, Group Homes, and Unlicensed/Unregulated Individuals Only:    Please list the total number of children in your care and relationship to you, if applicable.     

Total Number of Children in Your Care:    ________

Child’s Name:              Relationship to Provider:

PROVIDER RESPONSIBILITIES AND CERTIFICATION

1. Provider will continue to meet all minimum requirements set by the state and agrees to comply with all AMERICORPS CHILD CARE policies necessary for reimbursement.

2. Provider will notify AMERICORPS CHILD CARE immediately when a child stops receiving care.    It is understood that any parent must be given access to his/her child(ren) at any time during care hours.

3. Provider will mail the monthly coupon/attendance sheet NO LATER THAN the seventh (7th) day of the month following care or upon termination of care (if care stops before the end of the month).    PLEASE NOTE:    Reimbursement may be delayed if the attendance sheet is postmarked later than the 7th day of the month following care.    In addition, 24-hour or overnight care may not be legal in all states.

4. Provider will not charge a higher fee for children of AMERICORPS Members than for the same service to the public.    NOTE: Failure to adhere to this policy will result in provider being required to refund overpayments and in cancellation of this and future payments from AMERICORPS CHILD CARE.

5. AMERICORPS CHILD CARE will not pay additional fees for registration, late, transportation, meals, snacks, trips (ie., fieldtrips, etc.)    or any other miscellaneous fees.    Provider shall collect any such fees directly from the Member.

6. Provider agrees to repay AMERICORPS CHILD CARE any money received for which services were not provided.

7. Provider agrees to notify AMERICORPS CHILD CARE at least fifteen (15) calendar days before ending childcare services.    NOTE:    In cases of emergency please notify AMERICORPS CHILD CARE immediately (855) 886-0687).

8. I understand that my payment will be based on this completed voucher once received by AMERICORPS CHILD CARE staff.   

9. I further understand that any misrepresentation of information may result in legal action.       

The Member has chosen you to provide childcare services.    Prior to reimbursement, you must first provide all information requested on the front of this form, be determined a legal provider in your state, and the member must be determined and remain eligible to receive benefits through.

                      __________/__________/__________

Provider Signature                                                    Date

AMERICORPS CHILD CARE RESPONSIBILITIES

1. AMERICORPS CHILD CARE is responsible for coordination of childcare payments and other related support services as necessary to the children and families served under this agreement.

2. AMERICORPS CHILD CARE will pay only licensed and regulated providers for federal holidays and school vacations.    AMERICORPS CHILD CARE will also pay licensed and regulated providers for up to five sick/no-care days per month.    Excessive absences may require formal documentation (i.e.., doctor’s note).

3.    AMERICORPS CHILD CARE will not pay more than one provider, for the same child (ren), for the same period of care.

PARENT RESPONSIBILITIES AND CERTIFICATION

I [the member] understand that:

1. Childcare benefits for which I am eligible are based on my income, family size, age of child(ren), the provider’s location, and the type of child    care I select and that if there are any changes to my situation, I must make both my State Program Officer and AMERICORPS CHILD CARE aware of those changes.

2. I agree to complete the necessary documents (i.e., childcare coupons) on a timely basis, to ensure the provider may receive timely reimbursement.

3. I agree to submit proof of my continued eligibility for this program when requested.

4. I agree to notify AMERICORPS CHILD CARE at least fifteen (15) calendar days before ending childcare services.    In cases of emergency please notify AMERICORPS CHILD CARE immediately (855) 886-0687.

5. I further understand that any misrepresentation of information may result in legal action.   

6. I understand that the provider indicated on page 1 of this form must meet all state requirements to provide childcare services, and that AMERICORPS CHILD CARE is under no obligation to begin reimbursements before the provider has been determined legal.

I have read this agreement and understand that failure to comply with the terms of this agreement may result in the termination of my childcare benefits.

_______________________________________________________________      __________/__________/__________

AMERICORPS Member’s Signature              Date

MEMBER: PLEASE FORWARD APPLICATION AND PROVIDER FORMS TO YOUR PROGRAM DIRECTOR FOR SIGNATURES

PROGRAM DIRECTOR CERTIFICATION

I certify that the Member requiring childcare services as per this agreement is a full-time AMERICORPS Member and is eligible for childcare benefits through AMERICORPS CHILD CARE.    I authorize that funds designated for childcare be made available to AMERICORPS CHILD CARE for regular payment of services as described above.

                      ____/____/____

Program Director’s Name          Program Director’s Signature    Date                   

PROVIDER RATES DISCLOSURE

Please complete all sections below.    Mark “NA” in sections that do not apply to you.

Provider’s Name:                Tax ID or SSN:    _____-_____-_____

(If licensed/registered, must indicate name as it appears on license/registration)

            ______________________________                                                      __________________________                           

                              License Number                      Expiration Date    (COPY OF LIC/REG. MUST BE ATTACHED)                          

Ages Served:

Days of Operation:     Sunday       Monday       Tuesday       Wednesday       Thursday       Friday       Saturday

Hours of Operation: ___________________________________________________     

If provider is unlicensed/unregulated:    SSN    _____-_____-_____      (ATTACH A COPY OF SOCIAL SECURITY CARD)

    Or

If provider is licensed/regulated: Fed ID # _____-_____-_____        (ATTACH A COPY OF LICENSE OR REGISTRATION)

                              =======================================================================================

Check as appropriate:     

Type of Care:     FDC (Family Day Care Home)         Center                                 Group Home

Regulatory Status:     Unlicensed/Unregulated         Licensed/Regulated         Exempt (i.e. family member, friend) **

Child Care License No. /Registration No. (If applicable): _____________________________

Licensing Contact Name and Phone Number: __________________________          (_____) ______-_______

**YOU MUST MEET STATE GUIDELINES TO BE CONSIDERED LEGALLY EXEMPT; contact AMERICORPS CHILD CARE or your state licensing agency for more information.

PROVIDER RATES

 The rates listed below are the true and correct rates that I charge all parents for the care of their child (ren).

 I understand that AMERICORPS Child Care cannot pay me more than I charge private pay clients.

 I also understand that AMERICORPS Child Care cannot pay me more than the maximum rate(s) as established by the Child Care & Development Fund for my state.

 The rate specified is the charge for normal provision of childcare services.

 I understand that I must notify AMERICORPS Child Care at least 15 (fifteen) days prior to any rate change in order for the new rate to be honored.

 I understand that AMERICORPS Child Care cannot pay fees or charges for registration, transportation, meals, late pick-up, early withdrawal, or any other miscellaneous fees or charges.

 I also understand that in any of the above cases, the parent is responsible for such fees and/or charges.

 I understand that program or policy violations will result in having to repay money to AMERICORPS Child Care and/or suspension from future participation in the AMERICORPS Child Care childcare subsidy program.

Please list the rates that you charge per child.    The rates will still be negotiated by AMERICORPS Child Care.

AGE GROUP	FULL TIME WEEKLY	PART TIME WEEKLY	*24 HOUR/ OVERNIGHT (DAILY)	*“SPECIAL NEEDS” WEEKLY
UNDER 2 ½
2 ½ - SCHOOL AGE
SCHOOL AGE - 12

*Not reimbursable in all states.

I prefer payments be made by:   

                        ACH/Direct Deposit (Please complete the ACH Form)                          Check by mail          I hereby certify the above information is true and correct.   

     

      ______________________________________________                      __________/__________/__________

Provider’s Signature                                Date

        (If licensed or registered, this must be signed by Owner or Authorized Agent of Owner)

OMB Control Number: TBD  Expiration Date: TBD

Public Burden Statement: Public reporting burden for this collection of information is estimated to average 30 minutes per submission, including reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or content of this instrument may be sent to the Corporation for National and Community Service, Attn: Amy Borgstrom, 1201 New York Avenue, NW, Washington, D.C. 20525. CNCS informs people who may respond to this collection of information that they are not required to respond to the collection of information unless the OMB control number and expiration date displayed on page one are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)

Privacy Act Notice: The Privacy Act of 1974 (5 U.S.C § 552a) requires that the following notice be provided to you: The information requested on AmeriCorps Childcare Forms Instructions is collected pursuant to 42 U.S.C 12592 and 12615 of the National and Community Service Act of 1990 as amended, and 42 U.S.C. 4953 of the Domestic Volunteer Service Act of 1973 as amended. Purposes and Uses - The information requested is collected to evaluate applications for the childcare subsidy made available to AmeriCorps members by law, and to evaluate applications to provide the childcare. Routine Uses - Routine uses may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests. In some programs, the information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information may also be provided to appropriate federal agencies and Department contractors that have a need to know the information for the purpose of assisting the Department’s efforts to respond to a suspected or confirmed breach of the security or confidentiality or information maintained in this system of records, and the information disclosed is relevant and unnecessary for the assistance. The information will not otherwise be disclosed to entities outside of AmeriCorps and CNCS without prior written permission. Effects of Nondisclosure - The information requested is mandatory in order to receive benefits.