Get Ccdf V10 14

CHILD CARE and DEVELOPMENT FUND PROVIDER INFORMATION PAGE V10-14 Parent Guardian Name Caregiver s Name Business Name if applicable Street Address where care is provided City Zip County Social Security or EIN Number last 4 digits only Phone Fax Hours of Operation Days Please circle S M Tu W Th F S Child s Name first last Child s Age Years / Months Date Completed Kindergarten Indicate HD Day FD Full Day Type of Provider Licensed Home License Licensed Center Registered Ministry Registration License Exempt Home Providing care in child s home Current Charge List charges for SchoolAge School Year Week / Day / Hour Charge for next age group If child is currently 2 list charge at age 3 School-age summer/evening care Provider s Current Paths to QUALITY Level FOR SCHOOL AGE AND KINDERGARTEN FULL-DAY CARE School Year Begins Ends Does school-age child need break care vouchers No Yes If yes a school schedule must be provided. PROVIDER AFFIRMATION I affirm the information provided on this application form is true and correct. 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* Available on www. childcarefinder. in*gov* 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 Are you related to the children listed above If yes explain PLEASE NOTE Eligible providers must demonstrate compliance with CCDF Minimum Standards prior to participation in this program* 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. Your provider MUST be CCDF eligible. All provider changes must be received in our office by noon on Thursday each week prior to change taking effect. Please note that vouchers can not be backdated* No provider change will be made without an effective date listed above. We do not accept faxes. PROVIDER Please complete all information and sign the form in the box to the left. To check voucher status visit your provider website at www. hoosierchildcare. com* Contact the Child Care Resource and Referral Line CCRR at 1-800-299-1627 to locate and determine childcare in your area*. 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* Available on www. childcarefinder. in*gov* 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. childcarefinder. in*gov* 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 Are you related to the children listed above If yes explain PLEASE NOTE Eligible providers must demonstrate compliance with CCDF Minimum Standards prior to participation in this program* completed form to your appointment to assist in prompt completion of your child care vouchers.