### 1 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 (_______)________-_________

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) Relationsh ip 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

1. 

###       

2. 

###       

3. 

###       

4. 

###       

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: 

### AmeriCorps Member’s Name

: ____________________________________________ 

### NSPID #: ___________________

Date C ar e Begins: _____/_____/_____ Date Care Ended (if applicable): _____/_____/_____

### 2 PROVIDER RE SPONSIBILITIES 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 ca re 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 7 th day of the month following care. In addition, 24-hour or overnight care may

no t 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 provider s 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

### 3

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 

###  Ex empt (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.

### 4 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

su spension 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 HOU R/

OVERNIGHT (DAILY) * “SPECIAL NEEDS”

WEEKLY

UNDER 2 1⁄2

2 1⁄2

- 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 hereb y certify the above information is true and correct.

______________________________________________ __________/__________/__________

Provider’s Sign at ure Date

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