2 Member Application

AmeriCorps Child Care Member Application

Instructions: This application form must be completed in its entirety 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 Member 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.

MEMBER INFORMATION

AmeriCorps Member Name: (Last, First, Middle Initial)

Member’s National Service Participant ID #

________________

Your NSPID # can be found in the MyAmeriCorps Portal (if available)

Type of Application:

• New Application

For first time applicants.

• Re-Enrollment Application

For members beginning a new term.

Date of Birth:

____/____/______

Home Phone Number:

(____)-____-_______

Cell Phone Number:

(____)-____-_______

Preferred Contact Method:

• Phone

• Email

Email Address:

Street Address:

City:

State:

Zip Code:

Full time residence?

• Yes

• No

AMERICORPS SERVICE INFORMATION

Service Start Date:

____/____/______

Projected Service End Date: ________________________ _ ____/____/______

AmeriCorps Supervisor’s Name:

Supervisor’s Email Address:

Program Affiliation:

• AmeriCorps State and National

• AmeriCorps VISTA

• AmeriCorps NCCC/FEMA

Supervisor’s Phone #:

(____)-____-_______

Pre-Service Orientation Training Dates (for AmeriCorps VISTA members only):

____/____/_____ - ____/____/_____

Service Assignment Program Name:

Service Site Street Address:

City:

State:

Zip Code:

AMERICORPS SERVICE SCHEDULE

	DAY		START TIME	END TIME	TOTAL HOURS PER DAY
	MONDAY
	TUESDAY
	WEDNESDAY
	THURSDAY
	FRIDAY
	SATURDAY
	SUNDAY

*If you work weekends or extended hours, confirmation via an email or letter statement from your AmeriCorps Program Director or Site Supervisor will be required.

SPOUSE/DOMESTIC PARTNER INFORMATION

Name:

Street Address:

City:

State:

Zip Code:

Phone Number:

(____)-____-_______

Email Address:

Employment Status:

• Employed

Current Occupation - __________________

• Not Employed – Complete Section Below

Job Training/Educational Program-

Training/Educational institution:

___________________________________

Start Date - __/__/____

Projected End Date - __/__/____

Enrollment Status:

• Full Time

• Part Time

Seeking Work-

Last date of employment __/__/____

Information on former employment

Former Company: __________________________

Former Position: __________________________

Contact Name: __________________________

Phone number: (____)-____-_______

HOUSEHOLD INFORMATION

List all members of your household below (including roommates, significant others, etc.) For all children listed, please include relationship as biological, adopted, step child, foster, etc. Total # of household members _______
NAME OF HOUSEHOLD MEMBER	AGE	GENDER (M/F)	RELATIONSHIP TO MEMBER
			SELF

Other Household Members over 18?

Complete the following section below for all other household members not currently employed.

If they are employed, you may skip this section and submit a month’s worth of paystubs for employment verification.

Household member

Type of activity

Training/Educational institution

Start Date

End Date

• Seeking Work

• Training/Education

__/__/____

__/__/____

Please describe their schedule below: (including days of week and total hours)

Household member

Type of activity

Training/Educational institution

Start Date

End Date

• Seeking Work

• Training/Education

__/__/____

__/__/____

Please describe their schedule below: (including days of week and total hours)

INFORMATION FOR CHILD(REN) NEEDING CHILD CARE

CHILD’S NAME	ARE YOU RECEIVING A CHILD CARE SUBSIDY FOR THIS CHILD?					ATTENDING SCHOOL?
	YES		NO			YES				NO
										
										
										
										
SCHOOL SCHEDULE To determine the level of care needed for school aged children, tell us your child’s school information.
CHILD’S NAME	NAME OF SCHOOL				GRADE			SCHOOL SCHEDULE Example: 9 am – 2 pm.
CHILD CUSTODY Attach the child custody arrangement portion of your court order. An affidavit or written statement must be submitted if informally agreed upon.
CHILD’S NAME	SCHEDULE OF CHILD CARE NEED
	Fill in the boxes below with the hours your child will need care Example: 8 am – 6 pm
	SUN	MON	TUE	WED			THU		FRI		SAT

SUMMARY OF HOUSEHOLD INCOME

List the total Monthly Income for your entire household; income for all household members over 18 must be included. All boxes must be completed; please write N/A (non-applicable) if the question does not apply to you. If any of your household members are self-employed, please have them complete the Statement of Work Activity Form.

FORM OF INCOME	AmeriCorps Member	Spouse/ Domestic Partner	Household Member _____________	Household Member _____________
Wages, Salaries & Tips
AmeriCorps Stipend
Self-Employment
Adoption subsidies / Foster care payments
Alimony
Child Support
Nutritional Programs
Housing allotments or assistance
Military housing or other allotment / bonuses
Scholarships, education loans, grants, or income from work study
Social Security Income
Veteran Benefits
Unemployment Benefits
Temporary Assistance for Needy Families (TANF)
Worker’s Compensation
Other: _________________
TOTAL:	$________	$________	$________	$________
Disclaimer – Documentation will be required to support each of the declared forms of income.

MEMBER CONFIRMATION

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

I certify that:
	I am the parent or legal guardian of the child(ren) listed in this application and that I must submit verification of such in order to be eligible to participate in the AmeriCorps Child Care Benefits Program.
	I need the AmeriCorps Child Care Program benefit in order to serve.
	All information submitted in this application is true and correct.
	My total household income has been reported.
	The documentation submitted in support of the application is true and accurate copies that have not been altered from the original.

I understand that:
	This information is being given is required to determine if I am eligible for the program
	The AmeriCorps Child Care coordinators may verify any information on this application at any time they deem necessary.
	The child care benefit for which I may be eligible is based on income, household size, age of child(ren), the provider/program license type, and the provider/programs location. If there are any changes to my situation, I must report all changes to the AmeriCorps Child Care Program immediately.
	I must select a qualified child care provider/program that meets state and federal qualifications necessary to participate in the AmeriCorps Child Care Program. The AmeriCorps Child Care Program is under no obligation to begin payments until the provider/program has met all prerequisites as described in my State’s Child Care Development Fund Plan.
	I must give the AmeriCorps Child Care Program a minimum of 2 weeks’ notice when changing child care providers/programs and must turn in all necessary paperwork to process such provider. (See Provider Checklist under FORMS on www.americorpschildcare.com ).
	I may use more than one provider (or use a back-up provider); The AmeriCorps Child Care Program will not pay for the same period of care for the same child, to multiple providers.
	The AmeriCorps Child Care Program will only make all payments to my child care provider. Payments are distributed on a monthly basis, after the month of care has been provided. Payments are processed within 30 days of receipt of a completed attendance sheet. You, the AmeriCorps Member, are responsible for paying all child care charges in excess of the child care benefit amount.
	AmeriCorps members may not claim a child care benefit from AmeriCorps while also receiving a child care benefit from another source.

I understand/certify that 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 any misrepresentation of information may result in legal action.

______________________________ ____________________________ ____________

AmeriCorps Member Name (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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