Form Dcd-0404 - Application And Purchase Agreement For Child Care Transportation Services

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APPLICATION AND PURCHASE AGREEMENT FOR CHILD CARE TRANSPORTATION SERVICES
This is an application to enroll in the Subsidized Child Care Program as a transportation provider for child care. Also, this is an
agreement between the transportation provider and the local purchasing agency to provide transportation for subsidy children if the
transportation provider meets all requirements. The local purchasing agency is defined as any agency that administers the Subsidized
Child Care Program, such as the county department of social services or local child care resource and referral agency.
APPROVED TRANSPORTATION RATES (This Part Completed By Local Purchasing Agency Only)
APPROVED TRANSPORTATION RATES
Provider ID NO.:___________________________
Transportation Rates: $ ____________ Effective Date: ____________
Requested Effective Date of Enrollment:________
(children under age 3 or special needs)
Enrollment Approved?
YES
NO
Transportation Rates: $ ____________ Effective Date: ____________
(children age 3 and over)
Comments: _____________________________________________________________________________________________
NOTE: Local purchasing agency must complete this section in its entirety and provide a copy to transportation provider.
Part I Completed By:______________________________________________________ Date:__________________________
Child Care Coordinator/Supervisor
PART I: PROVIDER INFORMATION
1. Name of Transportation Provider:________________________________________________________________
2. Mailing Address:_______________________________________________________________________________
PO Box/Street/Rural Route
City
Zip Code
3.
LocationAddress:_______________________________________________________________________________
(If different from mailing address)
Street/Rural Route
City
Zip Code
4.
5.
Contact Person:________________________________________
Telephone:(
)______________________
6. County: ______________________________________________7.
Effective Date of Rates:_________________
PART II: AGREEMENT TO PROVIDE TRANSPORTATION FOR CHILD CARE
1.
I agree to provide transportation services to and from the child care arrangement, _____________________________
_____________________________________________________________ (name of child care facility)
subject to the
child's continued eligibility for the service and the parent's decision for the service to continue.
2.
I am an independent provider of transportation. I agree to indemnify and serve harmless the purchaser and the State
of North Carolina against any claims that would arise as a result of my being a transportation provider.
3.
I will comply with the provisions of the Civil Rights Act of 1964 and its subsequent amendments and with the
provisions of the Americans with Disabilities Act which may apply to me.
4.
Neither I nor any representative of my program have defaulted on or been debarred from any transaction with a public
agency, nor been convicted of any charge involving misuse of public funds or property, within the past three years.
5.
Neither I nor anyone who will be in contact with the children have been convicted of a crime involving child abuse,
child neglect, or moral turpitude; nor habitually use alcoholic beverages to excess or use illegal narcotics, or other
impairing drugs.
6.
At no time will I subcontract this service. If I am not available to continue providing transportation, I will terminate
services by giving a ten (10) workday notice to the local purchasing agency (the purchaser) and the parent.
7.
Because payment is made with state and federal funds, I understand that I must abide by the regulations, rules and
policies for use of each fund. I will operate legally according to state and local laws and will comply with the North
Carolina child care requirements applicable to the transportation of young children.
Continued on page 2
DCD-0404 (1)
Rev. 10/01

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