After School Parent Application for Assistance

After School Parent Application for Assistance
The Inter-Tribal Council of Nevada, Inc., Child Care Development Fund, has child care subsidies available for American Indian/Alaska Native families in your community.
To receive services, parents must be employed, enrolled in educational courses, and/or participating in job training. The eligible child must be of American Indian/Alaska Native descent and be 12 years of age or younger. Parents can choose the type of child care that is best for their family, whether it is private in-home care, licensed child care services, tribally administered child care, or licensed home child care. Providers must be 21 years of age or older, meet CCDF Health & Safety Standards, and local county child care standards. For private in-home care, providers can only be grandparents of the eligible child, and must submit to fingerprinting and a thorough background check.

The following items are required to determine eligibility:
- Parent’s Income
  - 1 paycheck stub or letter from employer verifying employment
- Other Documents
  - An official class schedule or official letter of enrollment, with proof of fees paid, is needed if attending educational courses, or proof of job training
The following forms are required in order to determine your child care subsidy:
- CCDF Application for Assistance (this form)
- Tribal Release of Funds (to download, go to our website http://itcnccdf.org/parents/)
All forms and documents must be completed and include authorized signatures in order to be reviewed for eligibility.

Applicants will receive written notification regarding their status. If you have any questions please call (775) 355-0600. Completed applications can also be mailed or dropped off to:

ITCN CCDF 10 State Street, 2nd Floor Reno, NV 89501

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Tribal Affiliation*
Parent/Guardian Date of Birth*

MonthDayYear
Date
Relationship to child(ren):*
If other, please list your relationship to the child(ren) here:*
How did you hear about CCDF?*
Have you previously received assistance from ITCN CCDF?*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Is there another legal guardian or biological parent of child(ren) residing in the same household (this includes spouses)*
Co-Applicant Name*

First NameLast Name
Co-Applicant Phone Number*
Please enter a valid phone number.
Co-Applicant Email*
example@example.com

Employment Information
If unemployed, please select a reason for needing child care:*
If other, please describe here:
Current Employer:*
If unemployed, please put N/A.
Position Title:*
Employment Status*
Hourly Wage/Weekly Salary ($):*
(Example: $15/hour)
Start Date*

MonthDayYear
Date
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone:*
Please enter a valid phone number.

Co-Applicant Employment Information
If unemployed, please select a reason for needing child care:*
If other, please describe here:
Co-Applicant Current Employer:*
Position Title:*
Employment Status*
Hourly Wage/Weekly Salary ($):*
(Example: $15/hour)
Start Date*

MonthDayYear
Date
Co-Applicant Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone*
Please enter a valid phone number.

Tribal Afterschool Provider Information
Tribal Afterschool Program:*
Tribal Afterschool Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Phone*
Please enter a valid phone number.
Provider Email*
example@example.com
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.

Document Upload

***Drag and drop as many files as necessary below***
Parent's Income-1 paycheck stub or letter from employer verifying employment*

Cancelof
Co-Applicant's Income-1 paycheck stub or letter from employer verifying employment*

Cancelof
Parent's Proof for Reason of Unemployment-An official class schedule or official letter of enrollment, with proof of fees paid, is needed if attending educational courses, or proof of job training*

Cancelof
Co-Applicant's Proof for Reason of Unemployment-An official class schedule or official letter of enrollment, with proof of fees paid, is needed if attending educational courses, or proof of job training*

Cancelof
Tribal Release of Funds Please go to our website: http://itcnccdf.org/parents/ to download the Tribal Release of Funds*

Cancelof

Protective Services
On a case-by-case basis, ITCN CCDF can provide services to families who fit ITCN CCDF’s definition of “protective services”. Under protective services ITCN CCDF can reimburse the child care costs for children who:

• Have been abused/neglected, or at risk of abuse or neglect (this includes two parent families where one parent is unable to care for the child due to an addiction to a controlled substance, that may put the child at risk,
• Are Homeless
• Are children of teen parents
• Are in transition
• And/or live with a parent/guardian who is unable to provide adequate care due to age, disability, physical/mental health condition, or financially incapable of care.
• Parent/guardian is an essential worker.

All cases must be referred and documented by protective services, and/or other appropriate agencies (i.e., law enforcement, courts, ICWA, case workers, etc.). If you are unable to acquire supporting documentation, an ITCN CCDF Case Manager can assist you. The family will be eligible for services for a period of 90 days. At that time, the family must re-apply for services, and include any changes in their status.
Does your family qualify based on the definitions above?*

YesNo
Under what definition does your family qualify?*
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
By initialing and signing this document, the applicant agrees that all information provided is true and accurate to the best of their ability. Any attempt to falsify information can result in denial of subsidized child care or immediate termination from the ITCN CCDF program. All information provided, can and will be verified with any, or all, tribal county, state, and federal agencies, to ensure accuracy of information, and to prevent duplication of services. ITCN CCDF also has the right to verify required information with applicant’s employers or child care providers. If at any time, the applicant requests to terminate their child care assistance with the ITCN CCDF program, the applicant must notify their Case Manager, immediately, and must fulfill all outstanding balances with their current child care provider.

Parent Agreement Form
I,First & Last Name, understand that:
Homework help is provided, but not the responsibility of the staff, nor is it the purpose for the program. My child is responsible for his/her own homework.

The program operates from: M T W Th F From: Time p.m. to Time p.m.

My child must sign-in and sign-out everyday my child attends in order to participate in weekly program activities.

I must complete all forms, i.e., Application, Registration, Child Expectation Contract, etc., including required signatures in order for my child to attend the program.

For safety reasons, unless stated on the registration form I will be responsible for dropping off and/or picking up my child during the program's operating hours, or I will designate an authorizer person to drop off or pick up my child.

No electronics are allowed during program hours; electronics include, but are not limited to: cell phones, iPods, iPads, video games, etc.
Child's Name (1)*

First NameLast Name
Child's Name (2)

First NameLast Name
Child's Name (3)

First NameLast Name
Child's Name (4)

First NameLast Name
Child's Name (5)

First NameLast Name
Child's Name (6)

First NameLast Name
Child's Name (7)

First NameLast Name
Date*

MonthDayYear
Date
Parent's Name*

First NameLast Name
Parent's Signature*

Clear
Date*

MonthDayYear
Date
Please sign and return with completed registration forms. Your child will not be able to attend the After School Program until signed copies of all forms are received.

Child Expectation Contract
This document serves as a child expextation contract between the Afterschool Program and your child. While in the program, students must follow all after school porgram rules.

Expectation of Students:
1. Attend the program regularly, unless sick, family emergencym or approved absence. (Poor attendance may result in being withdrawn from the program.)
2. If student will not be attending the After School Program, Parents/Guardians must notify After School Provider.
3. Actively participate in the program.
4. Have respect for all providers, tutors, elders, volunteers and other participants in the program.
5. Follow instructions, and do what is asked of you.
Discipline steps are as follows:
1. Verbal Warning (Letter to Parent/Guardian)
2. Written Warning (Letter to Parent/Guardian)
3. 3-day suspension from program
4. Removal from program
No electronics are allowed during the program hours, including, but not limited to: cell phones, iPods, iPads, video games, etc.
Child's Name (1)*

First NameLast Name
Child's Signature (1)*

Clear
Child's Name (2)

First NameLast Name
Child's Signature (2)

Clear
Child's Name (3)

First NameLast Name
Child's Signature (3)

Clear
Child's Name (4)

First NameLast Name
Child's Signature (4)

Clear
Child's Name (5)

First NameLast Name
Child's Signature (5)

Clear
Child's Name (6)

First NameLast Name
Child's Signature (6)

Clear
Child's Name (7)

First NameLast Name
Child's Signature (7)

Clear
Parent's Name*

First NameLast Name
Parent's Signature*

Clear
Media Consent & Release
The After School Program, as well as, the Inter-Tribal Council of Nevada, Child Care Development Fund program, is seeking your approval to have you and/or your child photographed and/or videotaped for educational, advertising, or outreach purposes.
I, blanks, hereby authorize the After School Program and ITCN CCDF, to photograph and/or videotape my child(ren), First & Last Name(s) , for the purposes stated above. By signing, I give consent to use the photos and/or videos in the matter listed above.
Date*

MonthDayYear
Date
Please sign and return with completed registration forms. Your child will not be able to attend the After School Program until signed copies of all forms are received.

Applicant Rights & Responsibilities
By initialing and signing this document, the applicant agrees that all information provided is true and accurate to the best of their ability. Any attempt to falsify information can result in denial of subsidized child care or immediate termination from the ITCN CCDF program. All information provided, can and will be verified with any, or all, tribal county, state, and federal agencies, to ensure accuracy of information, and to prevent duplication of services. ITCN CCDF also has the right to verify required information with applicant’s employers or child care providers. If at any time, the applicant requests to terminate their child care assistance with the ITCN CCDF program, the applicant must notify their Case Manager, immediately, and must fulfill all outstanding balances with their current child care provider.
Applicant Signature*

Clear
Today's Date*

MonthDayYear
Date
Co-Applicant Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

After School Parent Application for Assistance

Parent/Guardian Information

Employment Information

Co-Applicant Employment Information

Household Information

Tribal Afterschool Provider Information

Document Upload

Protective Services

Parent Agreement Form

Child Expectation Contract

Media Consent & Release

Applicant Rights & Responsibilities