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## AmeriCorps Child **C are**  **Member Application Instructions:**  This application form must be completed in its entiretyprior to submission to GAP Solutions, Inc.; failure to complete any section maydelay the processing of y our appl ication. Please write N/A (non - applicable) in the space provided should the question not appl y to y ou. A Member Checklist is available for y ou at http://www.americorpschildcare.com/Forms.aspx and outlines all of the required supporting documentation needed to accompany y our 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 begin ning 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: Am eriCorps **State and National** Am eriCorps **VISTA** Am eriCorps **NCCC /FEMA**  Supervisor’s Phone #: (____) -

____ -

_______ Pre - Service Orientation Training Dates (for AmeriCorps VISTA members only ): ____/____/_____ - ____/____/_____Page **2** of **6** 

## AmeriCorps Child **C are**  **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: Employ ment Status: Employ ed Current Occupation -

_________ ___ ______ Not Employ ed

– Complete Section Below Job Training/Educational Program Training/Educational institution :

___________________________________ Start Date - __/__/____ Projected End Date - __/__/____ Enrollment Status: Full Time Part Time Seeking WorkLast date of emplo ym ent __/__/____ In formation on former employ ment Former Compan y: _________________________ _ Former Position:

__________________________ Contact Name:

__________________________ Phone number: (____) -

____ -

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## AmeriCorps Child **C are**  **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 currentl y emplo yed. **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 day s 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 day s of week and total hours)Page **4** of **6** 

## AmeriCorps Child **C are**  **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 y our 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 y our child will need care Example: 8 am

– 6 pm **SUN MON**  **TUE WED**  **THU FRI**  **SAT**Page **5** of **6** 

## AmeriCorps Child **C are**  **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 y ou **.** If an y of yo ur household members are self - employ ed, please have them complete the **Statement of Work Activity Form** . **FORM OF INCOME**  **Am eriCorps**  **Member Spouse/ Domestic** 

**Partner Household** 

**Member**

**_____________ Household**  **Member**

**_____________** Wages, Salaries & Tips AmeriCorps Stipend Self - Employ ment Adoption subsidies / Foster care pay

ments Alimony Child Support Nutritional Programs Housing allotments or assistance Military housing or other allotment / bonuses Scholarships, education loans, grants, or income from work stud y Social Security In come Veteran Benefits Unemploy

ment Benefits Temporary

Assistance for Need y Families (TANF) Worker’s Compensation Other:

_________________ **TOTAL:** 

### $________ **$________ $________**  **$________ Disclaimer** 
**–** Documentation will be required to support each of the declared forms of income.Page **6** of **6** 

## AmeriCorps Child **C are**  **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 i ncome 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 an y 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 t yp e, 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/p**  **rogram 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.** Pay

ments are distributed on a monthly basis, after the month of care has been provided. Pay

ments are processed within 30 days of receipt of a completed attendance sheet. **You, the AmeriCor**  **ps 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
- p ay any money paid on my behalf and any misrepresentation of information may result in legal action.

______________________________ ____________________________ ____________ AmeriCorps Member Name (please print) AmeriCor ps Member Signature Today’s Date