Fillable CHILD CARE ASSISTANCE APPLICATION The Chickasaw Nation Child (The Chickasaw Nation)

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CHILD CARE ASSISTANCE APPLICATION The Chickasaw Nation Child (The Chickasaw Nation)

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Page 1 of 3 Form no. 04963 CS-EDU Rev. 8/2017
The Chickasaw Nation Child Care Assistance Program
P.O. Box 1548 / 300 Rosedale Rd. / Ada, OK 74820
(580) 421-7711 / (580) 436-0128 Fax
CHILD CARE ASSISTANCE APPLICATION
The application must be complete with the documentation listed below:
Child’s CDIB Card Child’s Social Security Card
Child’s Immunization Record Each Dependent’s State Birth Certificate
Household income
(Check copy - last 30 days) Utility Bill (Gas, electric, water - no older than 30 days)
Class Schedule (If attending college or training) Custodial/Child Support Documentation
(Must have if single, separated, divorced or guardian)
Doctor’s Report (If a member of the household is disabled) Social Security, Child Support or Any Additional
Income
APPLICANT INFORMATION
1. Child’s name 2. Sex 3. Age 4. Birth date 5. Social Security number
/ / - -
6. Address 7. Telephone number (work or school)
Address: ___________________________________
City & ZIP: _________________________________
E-mail: ___________________ County: __________
Work: ( ) ________-___________ Ext. _________
Home: ( ) ________-___________
Cell: ( ) ________-___________
8. Certificate of Degree of Indian Blood (CDIB) 9. Emergency contact (other than parents/guardians)
(a) Is child an American Indian? Yes No
(b) Does applicant have his/her CDIB? Yes No
(c) List tribe and degree:
__________________________________________
In case of emergency, notify:
Name: _________________________________________
Address: _______________________________________
Telephone: ( ) ________-___________
10. SCHEDULES (Work and school)
a. Mother’s or guardian’s schedule
____ Work
S M T W R F S
Time _______ to ______
____ School S M T W R F S
Time _______ to ______
____ Other S M T W R F S
Time _______ to ______
b. Father’s or guardian’s schedule
____ Work
S M T W R F S
Time _______ to ______
____ School S M T W R F S
Time _______ to ______
____ Other S M T W R F S
Time _______ to ______
ADDITONAL INFORMATION
Do you receive TANF benefits? Yes No
Does your child have a special need? Yes No If yes, please list needs:
Page 2 of 3 Form no. 04963 CS-EDU Rev. 8/2017
FAMILY STATUS
(Please check what best describes your situation)
(a) Single, head of household, never been married (d) Married
(b) Divorced
(e) Widowed
(c) Separated
(f) Common law
HOUSEHOLD INFORMATION
(List all members in the home)
11. Family member
(First and l
ast name)
Relationship
to the
applicant
Social Security
number
/ / Applicant - -
/ / - -
/ / - -
/ / - -
/ / - -
/ / - -
HOUSEHOLD INCOME
(List all income and provide verification of all income)
12. Member(s) receiving income:
(to include employment, child support,
work study, SSI, TANF, Disability)
Name & telephone number
of employer / hire date
Gross income and how
often you are paid
__________________________________
( )
$_________________
wkly bi-wkly bi-monthly monthly
__________________________________
( )
$_________________
wkly bi-wkly bi-monthly monthly
__________________________________
( )
$_________________
wkly bi-wkly bi-monthly monthly
__________________________________
( )
$_________________
wkly bi-wkly bi-monthly monthly
Eligibility determination is based upon a completed and signed application with the required documentation.
BEING FOUND ELIGIBLE DOES NOT GUARANTEE THAT AN INDIVIDUAL WILL RECEIVE
SERVICES. Placement is dependent upon availability of funds.
I certify the information I have submitted is true and correct to the best of my knowledge. I accept the
information is subject to verification; and falsification is grounds for immediate termination and may subject
me to prosecution under law. I allow the release of information for verification and reporting purposes.
_____________________________________________ ________________________
Signature of parent/guardian Date
_____________________________________________ ________________________
Signature of parent/guardian Date
Page 3 of 3 Form no. 04963 CS-EDU Rev. 8/2017
The Chickasaw Nation Child Care Assistance Program
P.O. Box 1548 / 300 Rosedale Rd. / Ada, OK 74820
(580) 421-7711 / (580) 436-0128 Fax
PROVIDER REGISTRATION & AGREEMENT FORM
CHILD’S NAME: ________________________________ Date: _______________
Each person or organization that receives payment from the Chickasaw Nation must
complete this form and return to:
The Chickasaw Nation Type: New Licensed Center One Star
Child Care Assistance Program
Renewal Licensed Home One Star Plus
P.O. Box 1548 / 300 Rosedale Rd.
Unlicensed Relative Two Star
Ada, OK 74820
Three Star
Name of provider: _______________________________ EIN/SSN: ____-__________ or ____-___-_____
Address: ______________________________________ Birth date: ______________________________
City & ZIP: _____________________________________ E-mail address: __________________________
County: _____________________________________ Telephone: ( )
_________-____________
Finding directions:
Are you a Native American? No Yes, Tribal affiliation: _____________________ Degree: ___________
If you are an unlicensed relative, what is your relationship to the child: ________________________________
***
Licensed centers & homes, please send a copy of your current
state license or permit, DHS Monitoring Report and Star Certificate
***
What is your licensed capacity? _________ What hours and days do you operate? ______________________
List maximum daily rates for the children for whom you provide care:
Full-Time 0-12 months $____________ Part-time 0-12 months $____________
13-24 months $____________ 13-24 months $____________
25-48 months $____________ 25-48 months $____________
49-72 months $____________ 49-72 months $____________
73 + months $____________ 73 + months $____________
Is this the amount that you charge everyone? Yes No, If no please explain:
____________________________________________________________________________________________
____________________________________________________________________________________________
The provider agrees the above information is correct to the best of his/her knowledge.
_________________________________________________________
Child care provider/owner Date
Staff use only:
Provider Information will be
filed in a central location.
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CHILD CARE ASSISTANCE APPLICATION The Chickasaw Nation Child (The Chickasaw Nation)

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Completed 31 January 2021

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