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 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 Address:  Email

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): 

____/____/_____ - ____/____/_____
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 AmeriCorps Child Care Member Application

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 ProgramTraining/Educational institution:

 ___________________________________

Start Date - __/__/____ 

Projected End Date - __/__/____ 

Enrollment Status:

 Full Time

 Part Time

Seeking WorkLast date of employment __/__/____

Information on former employment

Former Company: __________________________

Former Position: __________________________

Contact Name: __________________________

Phone number: (____)-____-_______
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 AmeriCorps Child Care Member Application

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)
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 AmeriCorps Child Care Member Application

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
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 AmeriCorps Child Care Member Application

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.
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 AmeriCorps Child Care Member Application

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 noncompliance 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