Child Care Provider Must Complete ENTIRE Section SECTION B – Completed by Child Care Provider (Please use ink or type) Child’s Full Name Child’s Child’s Total Hours Rate Type Amount Date Day Care Age Date of Child Care Charged (check Charged Started Birth Provided one box) Per Child Per Week Hourly Rate $ Weekly Rate Hourly Rate $ Weekly Rate Hourly Rate $ Weekly Rate Hourly Rate $ Weekly Rate Hourly Rate $ Weekly Rate Please list child care assistance paid to provider from other Source:_______ $_______ Child_______ sources such as Basic Sliding Fee, Early Childhood scholarship, Source:_______ $_______ Child_______ Transition Year, other parent receiving discounted rate, child Source:_______ $_______ Child_______ care scholarships or any other assistance programs, etc. Source:_______ $_______ Child_______ Source:_______ $_______ Child_______ Child Care Center / Provider’s Printed Name Relationship to Student (if any) Provider’s Street Address City, State, Zip Code County Provider Located Provider’s Phone Number Provider’s Email Address Land Line: ( ) Cell: ( ) Check all that apply: I am a licensed home child care provider. License number: ____________________________ I represent a licensed child care center. License number: ______________________________ I represent a latch-key program which has a contract with a school district to provide child care for school age children. I represent a child care center which is legally exempt from licensure. (YMCA, tribal daycare) I am at least 18 years of age. Under the exempt status I will only care for this family’s children, besides my own and I do not reside in the same household as the student and child. PROVIDER CERTIFICATION Please check every box next to each statement indicating that you understand the statement.
Child Care Provider Must Complete ENTIRE Section SECTION B – Completed by Child Care Provider (Please use ink or type) Child’s Full Name Child’s Age Child’s Date of Birth Total Hours Child Care Provided Per Week Rate Type Charged (check one box) Amount Charged Per Child Date Day Care Started Hourly Rate Weekly Rate $ Hourly Rate Weekly Rate $ Hourly Rate Weekly Rate $ Hourly Rate Weekly Rate $ Hourly Rate Weekly Rate $ Please list child care assistance paid to provider from other sources such as Basic Sliding Fee, Early Childhood scholarship, Transition Year, other parent receiving discounted rate, child care scholarships or any other assistance programs, etc. Source:_______ Source:_______ Source:_______ Source:_______ Source:_______ $_______ $_______ $_______ $_______ $_______ Child_______ Child_______ Child_______ Child_______ Child_______ Child Care Center / Provider’s Printed Name Relationship to Student (if any) Provider’s Street Address City, State, Zip Code County Provider Located Provider’s Phone Number Land Line: ( ) Cell: ( ) Provider’s Email Address Check all that apply: I am a licensed home child care provider. License number: ____________________________ I represent a licensed child care center. License number: ______________________________ I represent a latch-key program which has a contract with a school district to provide child care for school age children. I represent a child care center which is legally exempt from licensure. (YMCA, tribal daycare) I am at least 18 years of age. Under the exempt status I will only care for this family’s children, besides my own and I do not reside in the same household as the student and child. PROVIDER CERTIFICATION Please check every box next to each statement indicating that you understand the statement.
Postsecondary-Child-Grant-Application-17-18.docx