ATTACHMENT 1.doc

ATTACHMENT #1

CNSHQ-10-T-0009

MEMBER APPLICATION

Application submitted by the member will contain at least the following information:

Name of member

SSN, DOB, Address, ph no, email address

Name of children to be in child care

Copy of birth certificate of the child

Names, relationship, household income of all adults in household, with proof of income

Mailing address

Clear, bold, unambiguous directions informing the member of the terms of approval for the benefit:

They violate federal law if they provide false information

They may be prosecuted if they accept child care support from more than one source for the same child

AmeriCorps pays no more than that which the state pays for the same service for members of State & National and no more than $400 per child per month for VISTA and NCCC

They must use a provider that satisfies the requirements of the state

Payments go the provider, not the member

Payments go only to the provider

Attendance of the child must be verified by the provider and member

Member and provider must sign documents agreeing to all conditions and rules

Signature of member

Provider application

Application submitted by the child care provider will contain at least the following information:

Provider’s name (or name of the business)

Address

Phone number

Email address

Address where care is to be provided, including the county.

If licensed attach a copy of the license or registration

If unlicensed (for example a family member) include the SSN of the individual providing the care

Date care begins

Date care ends (if known)

Names of Children, SSN, birth date, Gender, relationship to provider

Signatures of the provider

Signature of the member

Application must contain cautionary information such as:

Child care cannot be paid for a child receiving care paid for by another source

Contractor must be notified immediately a child is no longer in care

No fees will be paid other than the monthly cost of child care

IF the member is with State & National

Name of sponsor (the organization for which the member is volunteering)

Supervisor or Program Director, name, address, ph no., email address, how to contact

Signature of Supervisor or Program Director (someone authorized to sign for the organization)

Grant No. of the grant (member may not know this but the sponsor must know this)

IF the member is VISTA

Name of sponsor

Supervisor or Program Director, name, address, ph no., email address, how to contract

IF the member is NCCC

Name of campus

Name of Director of Campus

(If we know the name of the campus we know how to find them)

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