Child Care Enrollment and Fee Verification Form

This form is to be completed by the director of the child care center or the child care provider and returned with the completed application.

PROVIDER INFORMATION

Name of Childcare / Center / Facility

Name of Director / Provider / Point of Contact

Room Assignment

If there are no room assignments in your facility, type "none"

Lead Teacher's Full Name

License #

NOTE: Providers must have a permanent licensing and be in good standing with KDHE.

Do you accept DCF funds?

Yes

No

Mailing Address

City

Zip Code

Email

Work Phone

Do you check email regularly?

Yes

No

Enrollment Information (via provider)

Child's Name (First & Last)

Start Date of Care

Is this child enrolled in full-time care?

Yes

No

Other

Tuition Amount $ (before any discounts or subsidies)

How is tuition charged?

Monthly

Weekly

Other

DCF payments, sibling / employee discounts $ (if applicable)

Other discounts $ (if applicable)

Child Care Center or Family Child Care Provider Expectations & Responsibilities

This completed page must accompany each scholarship application.

Be a licensed child care provider or center.

Maintain standards of health and safety set forth by KDHE and Child Care Licensing. If Raising Riley deems a facility's operations reflect issues regarding health and safety or non-compliance notices on the CCL portal, then a suspension from this partnership could result. This suspension will be the length of time a notice of non-compliance for health and safety issues remains on the KDHE CCL portal.

Located in Manhattan / Riley County.

Participate in a "Welcome to Raising Riley" orientation visit with a Raising Riley representative once scholarship is awarded. The representative will outline how to submit for your monthly reimbursement that are paid directly to the provider.

Complete and submit the Child Care Scholarship Request for Payment form monthly to receive scholarship payment.

Allow a Raising Riley representative to visit the home / center / classroom for observations up to twice per year.

Notify Raising Riley of any changes in scholarship family, employment status, additional tuition assistance, the number of hours a child is in care, or any intent to disenroll the scholarship child.

Raising Riley scholarship will not be used to "hold" spots for children in care.

Date of Submission

By selecting this checkbox and submitting this form, you are agreeing to the following statement:

"I certify that the information listed above is accurate to the best of my knowledge."