Maniilaq Association Employment & Training P.O. Box 256 Kotzebue, AK Ext: 7021 Fax: scholarships@maniilaq.

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1 Maniilaq Association Employment & Training P.O. Box 256 Kotzebue, AK Ext: 7021 Fax: We will not process applications without a background report, the request form is attached to this application. Kotzebue residents, go to the State Trooper s office, bring the $20 fee to request your background check. Non-Kotzebue residents, fill out the requestor background form and mail it with the $20 fee & check or M.O. payable to the State of Alaska, they will send the background report to you. Submit the background report along with the application to our office. E&T will reimburse the fee to you after receiving the application. Child Care Assistance- Provider Application We are pleased that you are interested in applying to be an approved Child Care Provider and we hope we are able to help. Upon approval of the Child Care client and provider, Maniilaq Association s Employment & Training will pay the full amount to the provider. The remaining percentage amount the client will have to pay will be sent to Maniilaq Association s Employment & Training. All Child Care Providers must complete new applications and required documents every 6 months to renew provider registration. Eligibility Criteria: All providers must have a State Business license or working toward obtaining a Business license. All providers must be CPR certified or working toward being certified. All providers must complete 20 hours of Child Care training. All providers must be able to pass a background check to be an approved provider with our child care program. If provider is caring for children in the providers home, all persons 18 and over in the household must pass a background check. All providers must turn in recent TB test results. All providers must be 18 years or older. A release of information must be signed by the provider. Required Documents: Submit these documents with the child care application. Note: no incomplete applications will be accepted. Copy of State ID Copy of Social Security Card TB test results (you can retrieve this information from your local clinic or Maniilaq Hospital) W-9 form completed (from attached on application) Criminal Background check printout (mail form attached with $20 fee to State or go to Kotzebue state trooper office and they will print it out for you. Maniilaq will reimburse the $20 fee after you submit receipt along with results) Criminal Background check for any other adults in the home where provider is caring for children. (Mail form attached with $20 fee to State or go to Kotzebue state trooper office and they will print it out for you. Maniilaq will reimburse the $20 fee after you submit receipt along with results) Copy of State Business license (Providers have up to a year to acquire this license, caseworker can provide more information) Copy of CPR Certificate (Providers have up to a year to acquire this license, caseworker can provide more information) Page 1 of 5

2 Employment & Training Child Care Provider Application Child Care Provider Information Name: First Middle Last Date of Birth: Social Security Number: Address: City State Zip Phone Number Business license # Exp. Date Provider: Are you related to the children? Yes No If so, How? How many children do you plan to provide day care for? What ages of children are you willing to serve? What hours are you willing to provide care? What days are you willing to provide care? Where is care provided? In my home In Parents home In a Center List all household members 18 years and older: Full Name Date of Birth Age List all household members 17 years and younger: Full Name Date of Birth Age Changes: Maniilaq Association s Child Care Program must be informed of changes that may occur in the household. Changes include new household members, change of physical location, when a child turns 18, household members listed move out. Background checks will also need to be submitted with new household changes. Page 2 of 5

3 YES NO Child Care Health/Safety Checklist (To be completed by parent and provider) 1. Are you 18 years of age or older? 2. Does anyone in the household have a criminal record? 3. Has everyone in the home 18 years old and over obtained a criminal background check? 4. Do you fully understand that you are required by law to report suspected child abuse? 5. Do you provide a smoke, drug and alcohol-free environment for the children in your care? This includes your child care site and vehicle used to transport children. 6. Does each floor of home have at least one properly installed and maintained smoke detector? 7. Do you have a fire extinguisher, which is readily accessible and in operable condition? 8. Do you have a first aid kit in a convenient location and is inaccessible to children? 9. Is ventilation, temperature and lighting adequate for children s safety and comfort? 10. Are poisons, toxic materials, cleaning substances, sharp or pointed objects and guns kept in a safe place or locked up so the children cannot get to them? 11. Is there a safe play area provided? Including inside and outside areas? 12. Are the floors and walls clean and maintained in a condition safe for children? 13. Does the child care provider have a plan to evacuate children in the event of a fire? 14. Are toys and objects (i.e. high chair) safe, durable, easy to clean and non-toxic? 15. Do you use any physical punishment (i.e. spanking or hitting), or any form of verbal abuse (i.e. name calling), which may hurt the child emotionally? 16. Are you aware of each child s location at all times and will protect the child from danger? 17. Are you able to prevent exposure of children to high-risk situations, including exposure to physical hazards and encounter with individuals or animals posing a possible danger? Page 3 of 5

4 Child s Health 18. Do you provide daily activities to promote a child s individual physical, social, intellectual and emotional development that includes time for sleep, toileting, indoor and outdoor play and exercise according to individual needs? 19. Do you provide sufficient nutrition so that: a. A child is fed nutritious meals and snacks according to individual needs; b. an infant is fed on demand; c. Except for medical reasons, a child is not denied a meal or snack, force fed or otherwise coerced to eat against the child s will. 20. All medicine, prescribed and/or over-the-counter, will be administered only with written parental instruction? 21. Do you use a separate towel and/or washcloth on the children? 22. Do you do diaper changing and toileting away from the food preparation area? 23. Do you keep emergency information on each child and contact the child s parent in case of illness or injury? 24. Do you provide the parent access to their child whenever their child is in your care? 25. Do you have a sample supply of safe, drinkable water in your child care home? Parent As the parent whose children will be provided child care from the person signing below, I certify that I have answered all of the questions honestly and to the best of my knowledge. Provider I certify that I will comply with all the requirements set forth by the Maniilaq Association, Employment & Training Child Care Development Fund Program, governing the registration of child care providers and that my answers to all the questions and statements I have made on the pages of this registration are true and correct to the best of my knowledge. Signature: Parent of Children Signature: Child Care Provider Date Date Page 4 of 5

5 Child Care Provider and Responsibilities As a provider participating in Maniilaq Association s Employment & Training Program, I agree to the following: 1. I must have a valid authorization before I submit any time sheets to Maniilaq Association s Employment & Training Program for participating parents. Charges for services provided which are not specified on the authorization are between the parent and myself and cannot be included on the Child Care time sheet. 2. I will have a current Alaska Business License to provide child care. I will provide Maniilaq Association s Employment & Training Program with copies of my required licenses. 3. I will apply for the Alaska State Business License within 12 calendar months of approval. 4. An authorization becomes invalid if my business license, child care, or other required license expires or is revoked. I understand I cannot bill Maniilaq Association s Employment & Training Program for services provided outside the effective dates of any required license. 5. I will meet all required health and safety standards. (attached as checklist) 6. Parents can visit the facility unannounced any time their child is in care. 7. I will notify parents and Maniilaq Association s Employment & Training Program before terminating service. Providers are required to give parents 14 days notice. Less than 14 days is acceptable if provider and parent mutually agree to discontinue services. 8. I will submit the original time sheet on the appropriate time sheet due date. Untimely submittal will result in delayed payment. 9. In the event of an unscheduled facility closure, I will notify all my parents as soon as possible. (Please ask each of your parents when they would like phone calls to inform them of closure due to you being sick.) 10. I understand that I may not misrepresent facts to receive subsidy payments. I understand that any benefits wrongfully received may result in denial of further participation in Maniilaq Association s Employment & Training Program. 11. I will respect and maintain the confidentiality of parents participating in the program. 12. Parents may review the time sheets for their children at any time. I will require parents to pay all charges within the scope of the authorization that are over the subsidized amount. I certify I have read, understand and will comply with my responsibilities under this child care program agreement. These responsibilities summarize state regulation and policies. In the case of interpretive conflict, regulations and policies take precedence. Signature of Provider Date Page 5 of 5

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