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## AmeriCorps Child **Care Provider Application** 

**Instructions:** This application form must be completed in its entirety b y the **child care provider and certified by the AmeriCorps member**  prior to submission to GAP Solutions, I nc.; failure to complete an y 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 Provider Checklist is available for you at http://www.americorpschildcare.com/Forms.aspx and outlines all of the required supporting documentation needed to accompan y 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 count y/ region is care provided? Ages Served: Total # of children in yo ur care: Regulatory

Status: Li censed / Regulated Exempt License T ype: Center Grou p Day Care Home Family Day Care Home Unlicense d (relative, friend of family, etc.) License # ____________________________ Expiration Date: ____/____/______Page **2** of **5** 

## 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 r elationship to provider**  ( if applicable )

**SCHEDULE OF CARE Child’s Name**  Fill in the boxes below with the hours y our 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 Providers**   Please submit an additional rate sheet with al l applicable charges and billing policies.Page ** 3** of **5** 

## 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 pay ments; upon receipt of a completed attendance sheet, pay ment will be disbursed within 15

- 30 day s. 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 day s per month; these day s must be marked on the attendance to be included for pay

ments (using “A” for absent or “H” for holiday ). Members and Provi ders should make mutually agreeable pay

ment arrangements for an y necessary upfront pay

ments or charges not covered by AmeriCorps Child Care benefit. Pay ments 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 overpay ments thus, resulting in the cancelation of future pay ments from AmeriCorps C hild 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 m y 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 r e - 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 Own er or Authorized Agent of Owner** Page **4** of **5** 

## 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 count y/ region care is provided, and the license ty pe of the provider I select. **If there are any changes to my situation, I mu st 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 receiv es timely pay ments. I understand that all payments will be sent to my child care provider. I agree to make mutuall y agreeable payment arrangements with my provider for an y necessary up - front pay

ments or charges/fees not covered b y 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 b y the AmeriCorps Child Care Program coordinators. I understand that the provider listed on the application m ust 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 al so 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 l egal action.

_____________________________ ____________________________ __________ AmeriCorps Member (please print) AmeriCorps Member Signature Today ’s DatePage **5** of **5** 

## AmeriCorps Child **Care Provider Application**