Reno-Sparks/Carson Urban Area Application for Assistance (V. January 2025)

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.

If additional documentation is needed to establish eligibility, ITCN CCDF reserves the right to request such information.
The following items are required to determine eligibility:
- Parent’s Identification
  - Valid Driver’s License/I.D. Card
- Parent’s Income
  - 4 paycheck stubs 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
- Children’s Birth Certificate
  - **Birth Confirmation will only be accepted up to 4 months**
- Child's Immunization Records
  - Immunizations must be current
- Proof of American Indian/Alaska Native Descent
  - Tribal Enrollment Card, BIA Certificate; or proof of descent
- Media Release
The following forms are required in order to determine your child care subsidy:
- CCDF Application for Assistance (this form)
- W-9 Form from your childcare provider **must be signed in the current year**
- Child Care License (for any licensed provider)
Home Providers will also need to submit the following documents:
- Two Finger Printing Cards
- Child Care Emergency Contact Information Form
- Provider Health and Safety Self-Certification Form
- Criminal Background Check Release Form
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*
How did you hear about CCDF?*
Parent/Guardian Date of Birth*

MonthDayYear
Relationship to child(ren):*
Have you previously received assistance from ITCN CCDF?*
Physical Address*

Mailing Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different than above)

Mailing Address

Street Address Line 2

CityState

Zip Code
Home Phone
Cell Phone*
Email*
example@example.com
Is there another legal guardian or biological parent of child(ren) residing in the same household (this includes spouses)*

YesNo
Co-Applicant Name*

First NameLast Name
Co-Applicant Phone Number*

Employment Information
If unemployed, please check here.
If unemployed, please select a reason for needing child care:*

SchoolJob TrainingOther
Current Employer*
Hourly Wage/Weekly Salary*
(Example: $15/hr or $1000/week)
Start Date*

MonthDayYear
Date
Employer Address*

Employer Address

Street Address Line 2

CityState

Zip Code
Employer Phone*
Position*
Employment Status*

Full-TimePart-Time

Co-Applicant Employment Information
If unemployed, please check here.
If unemployed, please select a reason for needing child care:

SchoolJob TrainingOther
Co-Applicant Current Employer*
Hourly Wage/Weekly Salary*
(Example: $15/hr or $1000/week)
Co-Applicant Employer Address*

Street Address

Street Address Line 2

CityState

Zip Code
Start Date*

MonthDayYear
Date
Employer Phone*
Position*
Employment Status*

Full-TimePart-Time

Household Information
Number of Adults in Home*
Number of Children in Home*
Family Size*
Single Parent?*

YesNo
Name of Child #1*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender*
Hours of Care Needed:*
Per Day or Per Week?*
Name of Child #2

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Hours of Care Needed:
Per Day or Per Week?
Name of Child #3

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Hours of Care Needed:
Per Day or Per Week?
Name of Child #4

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Hours of Care Needed:
Per Day or Per Week?
Name of Child #5

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Hours of Care Needed:
Per Day or Per Week?
Name of Child #6

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Hours of Care Needed:
Per Day or Per Week?
Name of Child #7

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Hours of Care Needed:
Per Day or Per Week?

Provider Information
Provider Type*

Licensed CenterGroup HomeFamily HomeGrandparentOther
Name of Provider*
Provider Address*

Provider Address

Street Address Line 2

CityState

Zip Code
Provider Phone Number*
Email*
example@example.com

Document Upload

***Drag and drop as many files as necessary below***
Parent's Identification-Valid Driver’s License/I.D. Card*

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Co-Applicant's Identification-Valid Driver’s License/I.D. Card*

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Parent's Income-4 paycheck stubs or letter from employer verifying employment*

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Co-Applicant's Income-4 paycheck stubs or letter from employer verifying employment*

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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*

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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*

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Child(ren)'s Birth Certificate(s)-**Birth Confirmation will only be accepted up to 4 months***

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Child(ren)'s Immunization Records-**must be current***

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Proof of American Indian/Alaska Native descent*

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Provider W-9 Form **must be signed in 2024***

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Child Care License*

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Provider Rate Sheet*

Cancelof

Media Release
I First & Last Name*, grant permission to the Inter-Tribal Council of Nevada, Child Care Development Fund (hereinafter known as the "media") to use mine and my child(ren)'s image (for photographs and/or video) for use in media publications including:
Videos
Photographs
Email Blasts
Printed Materials
Newsletters
General Publications
Website and/or affiliates

I hereby waive any right to inspect or approve of the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known or unknown to me, and I waive any right to royalties or other compensation arising from or related to the use of the image.
By signing below, I understand that I am the parent or legal guardian of the below named child(ren). I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian First & Last Name*

First NameLast Name
Child #1 Name

First NameLast Name
Child #2 Name

First NameLast Name
Child #3 Name

First NameLast Name
Child #4 Name

First NameLast Name
Child #5 Name

First NameLast Name
Child #6 Name

First NameLast Name
Child #7 Name

First NameLast Name
Child #8 Name

First NameLast Name

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.

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
Today's 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.

Applicant's Rights & Responsibilities

If you are applying with a co-applicant, please make sure both initials are on the application.
It is the applicant's responsibility to notify ITCN CCDF program of any changes that may affect eligibility.*

Clear
The applicant must also notify CCDF, in advance, if the applicant requests to change providers.*

Clear
CCDF is a parental choice program. The applicant determines the child care that is best for their family.*

Clear
Because of this, Inter Tribal Council of Nevada, Inc. is not responsible for any accidents or liabilities.*

Clear
Once approved for child care subsidies, no reimbursements for child care costs will be made until CCDF has received a contract, signed by the provider and parent, and the parent has participated in an intake interview, and completed the Parent Survey acknowledging all rules, regulations and parent responsibilities.*

Clear
The applicant will notify CCDF if their child needs, or needs to receive protective services, and/or*

Clear
Must submit supporting documentation that substantiates any special needs the child may have.*

Clear
It is the applicant's responsibility to make arrangements with the child care provider for any and all fees related the care of their child. CCDF reimburses for direct services only.*

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The applicant is responsible for all other costs, including, but not limited to: tuition, activity, registration or late fees, etc.*

Clear
The applicant must allow sufficient time for CCDF to verify that all information is correct, determine eligibility and process the application. Assistance will not begin until all necessary documentation has been received and all forms have been signed and submitted.*

Clear
In some instances, the application will be placed on hold and/or the applicant will be placed on the waiting list.*

Clear
CCDF will re determine the status of your eligibility every 24 months, or will re determine the status of your eligibility based on any changes reported by the Applicant, as needed.*

Clear
The Applicant must notify ITCN CCDF, if at any time during their eligibility contract assets exceed $1,000,000.*

Clear
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
All forms and information regarding the ITCN CCDF program can be found at: www.itcnccdf.org
Should be Empty:

APPLICATION FOR ASSISTANCE

Parent/Guardian Information

Employment Information

Co-Applicant Employment Information

Household Information

Provider Information

Document Upload

Media Release

Protective Services

Applicant's Rights & Responsibilities