Raising Riley Child Care Scholarship Application

What is a Raising Riley scholarship?
Through the Kansas Children’s Cabinet and Trust Fund’s Early Childhood Block Grant, the Raising Riley program (RR) has an opportunity to improve the affordability of child care. The scholarship program allows parents/guardians that live in Riley County the opportunity to receive financial assistance for child care if the preschool/daycare provider accepts RR funds. Raising Riley and the Riley County Health Department do not discriminate based on race, color, national origin, gender, age, disability, political beliefs, sexual orientation, religion and marital or family status. All information contained in this application is strictly confidential.

All parents/guardians must be ONE of the following:

Employed a minimum of 30 hours per week

Full-time student (full time high school student, full-time college student =12 hours, masters student=6 hours)

Part-time student & part-time employmentYour child must be birth through five years old (not yet eligible for kindergarten).

Your child must be ENROLLED in full-time care with a participating licensed provider that participates with Raising Riley

Other financial assistance received for child care, for example, any payments from DCF assistance, military child care assistance, discounts by providers, etc. must be reported.

Your application must be complete and all supporting documentation must be returned with it.

Temporary Scholarship Award: A temporary scholarship may be awarded for child care during the job search process. This award will be for a one month period. At the conclusion of the one month period application will be reviewed with the family.

Emergency Scholarship Award: A temporary scholarship may be awarded for child care during a family crisis. Each situation will be addressed individually.

Wait List: In the event of a wait list, applications will be reviewed and prioritized based on the Raising Riley Risk Factor Assessment.

Scholarship Recipient Information

Child's Information (Scholarship Recipient)

Gender

Male

Female

Where does your child attend care?

Does your child have an IEP or IFSP?

Individualized Education Plan (IEP)

Individualized Family Service Plan (IFSP)

None

Was your child born premature?

Yes

Have you been referred to our program by the Department of Children and Families?

Yes

Child Demographics

Child's Ethnicity

Hispanic/Latino/Spanish Origin

Non-Hispanic/Non-Latino/Not Spanish Origin

Child's Race

White

Black

Hispanic

Asian/Pacific Islander

Native American/Alaskan Native

Other

Child Health Insurance

Medicaid/State Children's Insurance Program

No Insurance

Private or Other

Tri-Care (Military Insurance)

Does this child speak a language other than English at home?

Yes

Child's Primary Language

English

Spanish

Other

Other Qualifying Information

Are you a Migrant Worker?

Yes

Are you experiencing a family emergency or have an individual need to be taken into consideration?

Yes

Have you received Raising Riley child care assistance in the past?

Yes

Parent/Guardian Information (Primary Contact)

Relationship to Child

Mother

Father

Other

Primary Caregiver's Ethnicity

Hispanic/Latino/Spanish Origin

Non-Hispanic/Non-Latino/Not Spanish Origin

Primary Caregiver's Race

White

Black

Hispanic

Asian/Pacific Islander

Native American/Alaskan Native

Other

Rather not disclose

Does primary caregiver speak a language other than English at home?

Yes

Primary Caregiver's Primary Language

English

Spanish

Other

Primary Caregiver's Highest Education Completed

Marital Status

Never Married

Married

Divorced

Widowed

Primary Caregiver's Health Insurance

No Insurance

Private or Other

Tri-Care (Military Insurance)

Household Information

Persons in household

Please list all residents living at your address. This includes roommates, family members, etc.

Resident 1

Resident 2

Resident 3 - If Applicable

Resident 4 - If Applicable

Resident 5 - If Applicable

Resident 6 - If Applicable

Housing Arrangement

Stable Housing

Temporary Housing

Homeless/living in shelter

In the past year has your family had to sleep in a temporary living arrangement?

Yes

All Income Sources

Wages

Maintenance

Worker's Comp

Temporary Assistance to Needy Families (TANF)

Unemployment

Social Security

Supplemental Security

Other

Primary Caregiver's Employment Information

Secondary Caregiver's Employment Information - If Applicable

If an adult has multiple places of employment, list incomes in the extra space provided below.

Does your family RECEIVE any of the following:

Child Support (direct or indirect)

Yes

DCF Child Care Subsidy

Yes

Discount or other reduction in tuition from child care provider

Yes

Any other assistance with child care?

Yes

REQUIRED: Please attach the following information (where applicable):

Most recent 3 paystubs or employment verification letter

Upload Image

OR

Upload Document

Documentation of marital status (legal separation agreement, divorce decree, etc.) - if applicable

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OR

Upload Document

International Students: Copy of lawful presence documentation and financial support letters from home government - if applicable

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OR

Upload Document

Student Self-Service Academic Certification form (can be printed from your KSIS account) or Enrollment Verification if attending school other than KSU. (Please select one)

Upload Image

OR

Upload Document

Child's IEP/IFSP - If Applicable

Upload Document

Responsibilities of Parent/Guardian

I declare that this application is true and correct.

I understand that if I receive a Child Care Scholarship to which I am not entitled as a result of providing false information, I must repay the cost of that assistance.

I understand that my child must be enrolled full-time care (35+ hrs/wk) with a licensed childcare provider.

Both parents/guardians must be individually employed and working at least 30 hours a week. Parents/Guardians attending school can qualify if enrolled fulltime in high school classes or enrolled in either 12 or more hours for undergraduate studies or 9 or more hours for a Master’s program. A combination of employment and school can be considered if the hours equal full-time status.

I understand that my eligibility status or scholarship amount may change to reflect any additional childcare subsidies.

I understand that information may be shared between RR and child care provider to verify eligibility.

I understand that it is my responsibility to provide proof of income, student status and other requested information needed to determine eligibility for this program and that failure to do so can result in my application/scholarship being denied.

I understand that proof of income, student status, and other requested information needed may be requested semi-annually or as often as the Raising Riley program deems necessary.

I understand that I must notify RR two (2) weeks prior to exiting scholarship program for any reason. Failure to do so could jeopardize future awards.

I grant permission to the Raising Riley Program to exchange information with other agencies offering family and child supports and services. (Ex: ACCYN, DCF, Child Care Provider, USD 383, Infant/Toddler Services, Riley County Maternal and Child Health, WIC)

I understand that award amounts are subject to change based upon availability of funds.

It is the parent/guardian’s responsibility to notify RR in writing within 5 days when a change in circumstances takes place, such as marital status, job changes, student status changes, income changes, additional child care subsidies received (ACCYN, DCF, SBA, etc.), new household members, new child care providers, etc. Failure to do so may result in loss of funding.

I understand that if I receive a Child Care Scholarship, I agree to:

Meet with an RR representative for orientation. Scholarship will begin when orientation is completed.

Allow mandatory assessments (3) to be completed by a Raising Riley representative as scheduled and participate in assessment follow-up discussions with Raising Riley respresentative.

Provide RR a two week notice when my child will be leaving the scholarship program for any reason. Exit developmental screenings must be completed by RR program in order for final month’s scholarship reimbursement to be dispersed. If not completed due to parent/guardian non-notification, scholarship will be suspended for last month’s attendance and parent/guardian is responsible for payment in full to provider.

I understand that Raising Riley reserves the right to refuse services based on non-compliance with this participation agreement.

To Whom it May Concern:

I hereby authorize any person, agency, or institution to supply information concerning myself or my family as requested by Riley County Health Department - Raising Riley and to allow inspection and reproduction of records in their possession by any duly authorized representative of Raising Riley and the Riley County Health Department. I herewith release any person, agency or institution from any and all liability to myself or to my family for supplying such information. This authorization is given only in connection with its use by Raising Riley and the Riley County Health Department in its administration of Raising Riley programs and for no other purpose.

Please be sure to complete the Enrollment & Fee Verification form with your provider. You or your provider can access this form at www.raisingriley.com located under the provider tab. You may also access this form in a new browser window by clicking the button below.

Enrollment & Verification Form

Thank you for your interest in the Raising Riley Child Care Scholarship Program. Please allow up to 3 business days for Raising Riley to process your application. If you have any questions about your application please feel free to contact the Raising Riley office at (785) 776-4779 ext. 7663

Thanks for submitting!