Child Care And Development Fund Provider Information Page

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CHILD CARE and DEVELOPMENT FUND PROVIDER INFORMATION PAGE
(V10-14)
Parent (Guardian) Name _______________________________________________________
Date Completed _________________________________________
_________________________________________
_________________________________________
Caregiver’s Name
Business Name (if applicable)
Street Address (where care is provided
) ____________________________________
Type of Provider
Licensed Home
License # ________________________
_______________________
_____________
__________________
City
Zip
County
Licensed Center
License # ________________________
Registered Ministry
Registration #_____________________
Social Security or EIN Number (last 4 digits only)
______________________________
License Exempt Home
License Exempt Facility
Phone
(
) ________________________
Fax
(
) ________________________
Providing care in child’s home
Hours of Operation ______________________ Days (Please circle) S M Tu W Th F S
Charge
Current Charge
for next age group
School-age
Provider’s
Kindergarten
(List charges for School-
(If child is currently 2
(List charges for
Current
Indicate
Child’s Age
Age School Year)
list charge at age 3)
summer/evening
HD = ½ Day
Paths to
Child’s Name (first & last)
Years / Months
Week / Day / Hour
Week / Day / Hour
care)
FD = Full Day
QUALITY™
Week / Day / Hour
Level
FOR SCHOOL AGE AND KINDERGARTEN FULL-DAY CARE
Are you related to the children listed above?______ If yes, explain ______________________
PLEASE NOTE: Eligible providers must demonstrate compliance with CCDF Minimum Standards prior to
School Year Begins ____________________ Ends _______________
participation in this program.
Does school-age child need break care vouchers? _____ No _____Yes
Parent / Guardian: Your caregiver must complete this information in its entirety. Your CCDF provider
If yes, a school schedule must be provided.
must allow unscheduled visits by a parent or legal guardian to their child care program during the hours
the child care program is in operation. Please bring the completed form to your appointment to assist in
prompt completion of your child care vouchers. If you wish to make a provider change, you must obtain
new vouchers prior to attendance or payment for care may become your responsibility.
PROVIDER AFFIRMATION
I affirm the information provided on this application form is true and correct.
PROVIDER: Please complete all information and sign the form in the box to the left.
Further, I affirm child care will be provided at the address listed above and
agree to comply with the rules and regulations of the CCDF program.
If you have any questions, please contact
(Available on I also understand I must allow
unscheduled visits by a parent or legal guardian to my child care program
during the hours my child care program is in operation.
In signing this application, I certify I am the individual listed above or the
authorized designee.
Signed, _________________________________________________

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