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 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 (nonapplicable) 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: ____/____/______
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 AmeriCorps Child Care Provider Application

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 ProvidersPlease submit an additional rate sheet with all applicable charges and billing policies.
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 AmeriCorps Child Care Provider Application

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
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 AmeriCorps Child Care Provider Application

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 

 
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 AmeriCorps Child Care Provider Application