Form 1 Provider Application

AmeriCorps Child Care Provider Application

Instructions: This application form must be completed in its entirety by the child care provider and certified by the AmeriCorps member prior to submission to GAP Solutions, Inc.; failure to complete any section may delay the processing of your application. Please write N/A (non-applicable) in the space provided should the question not apply to you. A Provider Checklist is available for you at http://www.americorpschildcare.com/Forms.aspx and outlines all of the required supporting documentation needed to accompany your application when it is submitted.

AMERICORPS MEMBER INFORMATION

AmeriCorps Member Name:

National Service Participant ID #:

_____________

CHILD CARE PROVIDER INFORMATION

Child Care Provider’s Name:

Phone Number:

(____)-____-_______

Fax Number:

(____)-____-_______

Preferred Contact Method:

• Phone

• Email

Email Address:

Home Street Address:

City:

State:

Zip Code:

Address where care is being provided:

City:

State:

Zip Code:

Providing care in the child(ren)’s home?

• Yes

• No

Providers cannot reside with the AmeriCorps member.

Hours of Operation

Check all that apply and fill in the hours:

• Monday ____ am to ___ pm

• Tuesday ____ am to ___ pm

• Wednesday ____ am to ___ pm

• Thursday ____ am to ___ pm

• Friday ____ am to ___ pm

• Saturday ____ am to ___ pm

• Sunday ____ am to ___ pm

In which county/region is care provided?

Ages Served:

Total # of children in your care:

Regulatory Status:

 Licensed / Regulated  Exempt

License Type:

 Center  Group Day Care Home  Family Day Care Home  Unlicensed

(relative, friend of family, etc.)

License # ____________________________ Expiration Date: ____/____/______

CHILD CARE INFORMATION

Date Care Began:

____/____/______

End Date of Care (if applicable):

____/____/______

Children to be cared for through the AmeriCorps Child Care Program -

Name of Child

AGE

Gender (M/F)

Child’s relationship to provider

(if applicable)

SCHEDULE OF CARE

Child’s Name

Fill in the boxes below with the hours your child will need care

Example: 8 am – 6 pm

Sun

Mon

Tues

Wed

Thu

Fri

Sat

RATE INFORMATION

In the table below, list your rates. If any do not apply to you, please write N/A.

Age Range	Hourly	Part Day	Full Day	Part Week	Full Week	Part Time Month	Full Time Month
Infants
Toddler
Preschool
School Age

Licensed/Registered Providers-

Please submit an additional rate sheet with all applicable charges and billing policies.

CHILD CARE PROVIDER CONFIRMATION

Please initial each box to verify that you have read and understand the policies listed below:

As a child care provider I understand that:
	Providers must continue to meet all minimum requirements set by the state and agree to comply with all AmeriCorps Child Care policies necessary for reimbursement.
	Providers must be 18 or older, and cannot reside with the member.
	Providers will notify the AmeriCorps Child Care Program immediately when a child stops attending.
	Providers will submit monthly attendance sheets to receive payments; upon receipt of a completed attendance sheet, payment will be disbursed within 15-30 days.
	The AmeriCorps Child Care Program will not pay additional fees for registration, late fees, transportation, meals/snacks, field trips, or any other miscellaneous fees.
	The AmeriCorps Child Care Program will pay only licensed and regulated providers for up to five sick/no-care days per month; these days must be marked on the attendance to be included for payments (using “A” for absent or “H” for holiday).
	Members and Providers should make mutually agreeable payment arrangements for any necessary upfront payments or charges not covered by AmeriCorps Child Care benefit.
	Payments will be mailed, and will be sent to the address listed on the Form W9.
	Providers will not charge a higher fee for children of AmeriCorps members for the same services. Providers overcharging AmeriCorps members will be required to pay back for overpayments thus, resulting in the cancelation of future payments from AmeriCorps Child Care.
	The AmeriCorps Child Care Program cannot pay me more than the maximum rate(s) as established by the Child Care and Development Fund (CCDF) for my state. All charges above what the benefit amount covers must be collected from the AmeriCorps Member.
	AmeriCorps members may not claim the AmeriCorps child care benefit while also receiving a child care benefit from another source.

I have read all of the above and understand its content. I also understand that non-compliance with any of the above may result in termination of my participation in the AmeriCorps Child Care Program as a child care provider and that I may be required to re-pay any money paid if in violation of the above mentioned policies and misrepresentation of information may result in legal action.

_____________________________ ______________________________ ___________

Child Care Provider (please print) Child Care Provider’s Signature Today’s Date

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

AMERICORPS MEMBER CONFIRMATION

Please initial each box to verify that you have read and understand the policies listed below:

I certify that:
	I have read and understand the above child care provider policies above (Child Care Provider Confirmation on page 3 of this application).
	I understand that the child care benefits for which I am approved for are based on my income, family size, age of child(ren), the county/region care is provided, and the license type of the provider I select. If there are any changes to my situation, I must report all changes to the AmeriCorps Child Care Program immediately.
	I certify that the provider I have chosen does not reside with me.
	I agree to complete required attendance sheets on a timely basis to ensure that my child care provider receives timely payments.
	I understand that all payments will be sent to my child care provider.
	I agree to make mutually agreeable payment arrangements with my provider for any necessary up-front payments or charges/fees not covered by the AmeriCorps Child Care Program.
	AmeriCorps VISTA and NCCC members have a $400 monthly maximum per month per child. This is not a monthly guaranteed amount but rather a maximum that the benefit cannot exceed.
	The AmeriCorps Child Care Program will not pay for the same period of care for the same child, to multiple providers.
	I agree to submit proof of my continued eligibility for this program when requested by the AmeriCorps Child Care Program coordinators.
	I understand that the provider listed on the application must meet all state requirements to provide child care services and that the AmeriCorps Child Care Program is under no obligation to begin reimbursements before the provider has been approved.

I have read all of the above and understand its content. I also understand that non-compliance with any of the above may result in termination of my participation in the AmeriCorps Child Care Program and that I may be required to re-pay any money paid on my behalf and misrepresentation of information may result in legal action.

_____________________________ ____________________________ __________

AmeriCorps Member (please print) AmeriCorps Member Signature Today’s Date

The information requested on the AmeriCorps Childcare Application forms 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 contractors that have a need to know the information for the purpose of assisting the agency’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. 

OMB Control Number: 3045-0142

Expiration: October 31, 2018

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