1 Provider Application

^{AmeriCorps Childcare Provider Application}

Privacy Act Statement (PAS)

Authorities – This information is requested pursuant to the National and Community Service Act of 1990 as amended (42 USC 12501 et seq.), the Domestic Volunteer Service Act of 1973 as amended (42 USC 4950 et seq.), and E.O. 9397 as amended. Purposes – It is requested to manage, administer, and evaluate the childcare benefits program offered to eligible AmeriCorps Service Members. Routine Uses – Routine uses of this information may include disclosure to (1) contractors to assist with administering the childcare benefit, (2) individuals and organizations providing childcare, and (3) federal, state, or local agencies pursuant to lawfully authorized requests. A complete list of uses can be found in the system of records notice associated with this collection of information, CNCS–06–CPO–ACB–AmeriCorps Child Care Benefit System (ACB). Effects of Nondisclosure – This request is voluntary, but not providing the information will likely affect your ability to receive childcare benefits.

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 (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. The checklist outlines all of the required supporting documentation needed to accompany your application when it is submitted.

AMERICORPS MEMBER INFORMATION

AmeriCorps Member’s Name:

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

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 is care provided?

Ages Served:

Total # of children in your care:

Regulatory Status:

 Licensed / Regulated License # ____________________________ Expiration Date: ____/____/______

 Exempt

License Type:

 Center  Group Day Care Home  Family Day Care Home  Unlicensed

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 Providers:

Required- Please submit an additional rate sheet with all applicable charges and billing policies. This can be from a parent handbook, registration paperwork, program flyer/pamphlet, etc.

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 may not be the other parent or adult sibling in the home.
	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 10 business days.
	Unless my state of residence allows, 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). If you reside in Washington State, you may be eligible for more than 5 absence days per child per month.
	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 either mailed or deposited (if enrolled in Electronic Deposit). If a check is mailed to you, it 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 prosecution under applicable state and federal law.

_____________________________ ______________________________ _______

Child Care Provider (please print) Child Care Provider’s Signature Date

If licensed or registered, this must be signed by Owner or Authorized Agent of Owner

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 policies and I approve the child care provider listed on this form to provide care for my child(ren).
	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.
	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 Date

OMB No.: 3045-0142 expires 12-31-2021 Page 4 of 4