State Early Childhood Education Scholarship Application

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1 State Early Childhood Education Scholarship Application Information about the program Use this application to apply for the State Early Childhood Education (ECE) Scholarships program. This program provides scholarships to help families pay for child care/early education to help their children get ready for school. Scholarships will be paid directly to the early childhood providers chosen by the parent. Please do not use this application to apply for the Minnesota Child Care Assistance Program (CCAP). If you receive funding for child care through CCAP, you are also eligible for the State ECE Scholarship program. If you pick an approved program, you can use the ECE Scholarship to pay for parent charges or fees that are not covered by CCAP. To qualify, your family must meet the following requirements: 1) Your family must live in one of these geographic areas: Becker County Blue Earth County Clearwater County City of Duluth City of Minneapolis Nicollet County City of St. Paul Pine County Wayzata School District City of Willmar 2) Your family must have an income at or below 47% of the State Median Income (see the chart below). Family Size Gross income 2 $27,350 3 $33,786 4 $40,221 5 $46,656 6 $53,092 7 $54,299 8 $55,505 9 $56, $57, $59, $60, $61,539 *Based on FY2013 SMI published in Federal Register on 3/15/2012 3) You must have one or more children between the ages of three and five years old who are not yet eligible to attend kindergarten. 4) You must be a parent or legal guardian of a child between the ages of three and five years old who is not yet eligible to attend kindergarten. 1

2 How to complete the application: 1) Answer all questions on the form and attach the required written documentation. 2) Carefully read the verification, consent, and data privacy sections of the application. 3) Sign and date the application. 4) Mail or bring the completed form and all other required items to the address listed below. Do not fax this form. Mail the application to: Think Small State ECE Scholarships 10 Yorkton Court St Paul, MN What happens next? Staff at your Early Childhood Education Scholarship office will send you a letter to let you know if your child or children qualify for a State ECE Scholarship(s). Questions/need assistance? If you have questions, contact the scholarship administrator at

3 Section I. Family Information 1. Parent/Guardian (applicant) information. Fill in the table below. First Name Last Name Relationship to Child Address City County State & Zip Code Mailing address (if different) City County State & Zip Code Home phone number Work phone number Other phone number Do you need an interpreter? (optional) Preferred spoken language (optional) 2) Tell us about your children who are between the ages of three and five years old and not eligible to attend kindergarten. Fill in the table below. Child s First Name Child s Middle Name Child s Last Name Child s Birthdate Section II. Income Verification You have two options for verifying your income. You only need to choose one of the options to apply. Option 1: You can provide proof that your child is participating in a publicly funded program. Option 2: You can list out your income and attach proof of this income. *****Option 1***** 1) Are any of the children listed in the chart above currently identified as eligible for one of the following programs? Check any that apply. Minnesota Family Investment Program (MFIP) Child Care Assistance Program (CCAP) Food Support (SNAP) Free and Reduced-Price Lunch Program Child and Adult Care Food Program Head Start Foster care Food Distribution Program on Indian Reservations 3

4 2) Proof of eligibility. If your child is eligible for any of the programs listed above, you must attach written documentation showing eligibility for ONE of the programs. If you do not have written documentation showing eligibility, please use the verification letter in Attachment A (page 9). ***Option 2**** 1. Parent/legal guardian income. Fill in the table below. List all sources of income received by you and any other of your children s parents or legal guardians who live in your household. Name of parent or legal guardian in Household (including yourself) Household Incomes Write in each gross income before deductions (not take-home pay). Write in how often each income is received: weekly (W), bi-weekly (every other week) (BW), twice per month (TM), monthly (M) or yearly (Y). Do not write in an hourly wage. If income fluctuates, write in the amount normally received. For farm or self-employment income only, list net income (after deductions). Attach additional page if needed. First Name: Last Name: Gross Wages and Salaries from all jobs - before deductions - $ per $ per $ per Pension, SSI, Retirement, Social Security $ per $ per $ per Public Assistance, Child Support, Alimony $ per $ per $ per Unemployment, Worker s Comp, Strike Benefits $ per $ per $ per Any Other Income, including net Farm/ Self- Employment $ per $ per $ per 2. Proof of income. Attach proof of income for each parent/legal guardian listed. Proof of income may include: a recent tax form, W-2 form, pay stub, financial aid statement, or a statement from your employer. 3. Family size. Fill in the table below to tell us about the number of family members living in your household* Type of family member Number of parent(s)/legal guardian(s), including yourself. Number of children under age 18. Number of children over 18 who live with you and are full-time students and you provide 50 percent or more of their financial support. Total family members living in the household (add up all of the numbers) Number in your household *If you are a minor parent living with your parents or relatives, include only yourself, your spouse or parents of your children living with you and your children. 4

5 Section III. Early Childhood Education Program Choice You may use your Early Childhood Education Scholarship at any eligible program in Minnesota. The provider that you choose does not have to be located in your geographic area. A program is eligible to receive a scholarship if they are participating in the Parent Aware Quality Rating and Improvement System. Parent Aware is a rating tool for selecting high quality child care and early education. Go to for more information about Parent Aware. Programs are eligible to receive a certain amount of scholarships per child based on where they are in the Parent Aware process. The chart below shows the scholarship amount based on the rating level: Program rating level 3 or 4-star Parent Aware rating 1 or 2-star Parent Aware rating Signed up for Parent Aware but haven t received a rating. Scholarship amount per child Up to $4,000 per child Up to $3,000 per child Up to $2,000 per child 1. Please tell us about where you want to use your scholarship. If you are awarded a scholarship, do you know where you will use it? Check yes or no. Yes. Please list the program name, address, and phone number in the table below. The scholarship administrator will help you figure out if that program is eligible to receive a scholarship and if they have a slot available for your child. Child s name Program name Program address/city/state Program phone number (if known) Check this box if your child is currently in this program. No/Not sure. If your child is found eligible for an ECE Scholarship, your ECE Scholarship Administrator will help you choose a program. If your child is currently attending a program but you would like to explore other options, your ECE Scholarship Administrator will also help you with this. 5

6 Section IV. Verification You do not have to give the information in this application, but if you do not, we cannot approve your child(ren) to participate in Early Childhood Scholarships. I certify (promise) that the information provided on this form is true and that all household income is reported. I understand that if I purposely give false information, my children may lose Scholarship benefits and I may be prosecuted. I give my consent for Early Childhood (ECE) Scholarship administrative staff to share information about my application for the ECE Scholarship, my eligibility for and the amount of any ECE Scholarship that I receive, with the early childhood education program that I choose to use my scholarship in. I understand that this information must be shared to determine whether I am eligible for the ECE Scholarship and to allow the ECE Scholarship to be paid to the program on my behalf. Signature of parent/legal guardian_ Date Printed name of parent/legal guardian Release of information for evaluation/consent to participate in evaluation I give my consent for Early Childhood Education Scholarship staff to share my information with the entity chosen by the Minnesota Department of Education (MDE) to evaluate the ECE Scholarship program. I understand that my information must be shared so that MDE can evaluate the Early Childhood Education Scholarship program. I understand that the evaluation will analyze how ECE Scholarship Funds are spent, how families are informed about the Scholarship program, and the impact on the child s development. They will include measurement tools to analyze the findings, including tools to measure child development in the five developmental domains of physical development, language and literacy, the arts, personal and social development, and mathematical thinking. Any public reports that include child information will be aggregated and will not include specific identifying information about any individual child. Refusal to consent to participate in the evaluation does not impact your eligibility to receive an Early Childhood Education Scholarship. Signature of parent/legal guardian Date Printed name of parent/legal guardian 6

7 Optional Information Optional information: The information on this page is optional. It is intended only for evaluation of the program and will not be used to determine eligibility. 1) How did you hear about the early childhood education scholarships? 2) Fill in the table below regarding the ethnicity and race of the children in your household who are between the ages of three and five and not yet eligible for kindergarten. Child s Ethnicity (optional) Child s Race (optional) Child 1 Child 2 (if applicable) Child 3 (if applicable) Child 4 (if applicable) Hispanic Yes No Hispanic Yes No Hispanic Yes No Hispanic Yes No Black or African American American Indian/Alaska Native Pacific Islander/Native Hawaiian White Black or African American American Indian/Alaska Native Pacific Islander/Native Hawaiian White Black or African American American Indian/Alaska Native Pacific Islander/Native Hawaiian White Black or African American American Indian/Alaska Native Pacific Islander/Native Hawaiian White 7

8 Minnesota Department of Education State Early Childhood Education (ECE) Scholarships Program Tennessen Warning What information are we requesting? We are requesting all information on the State Early Childhood (ECE) Scholarships program application. This application requests information that may be considered private data under Minnesota law. Why do we ask you for this information? Information on this application is required to apply for the ECE Scholarships program. We will use the information collected via this application or any additional communications related to this application to determine eligibility for the ECE Scholarships program. This information is also necessary to comply with the state law authorizing the ECE Scholarships program. Am I required to provide this data? There is no legal obligation for you to provide the data requested. However, absent the data requested, the Minnesota Department of Education will not be able to evaluate your child s eligibility for the ECE Scholarships program. Who else may see this information? A third-party entity will evaluate the effectiveness of the ECE Scholarships program for the Minnesota Department of Education. That entity is bound by Minnesota s data practices and privacy laws and may not share your data with any other private entities but will share its evaluation with the Minnesota Department of Education. We may also give the data you ve provided to the Legislative Auditor, the Minnesota Department of Human Services and any law enforcement agency or other agency with the legal authority to access the information, and anyone authorized by a court order. How else may this information be used? We can use or release this information only as stated in this notice unless you give us your written permission to release the information for another purpose or to release it to another individual or entity. The information may also be used for another purpose should the United States Congress or the Minnesota Legislature pass a law allowing or requiring us to release the information or to use it for another purpose. How long will my data be kept? Your data will be maintained for up to nine years. 8

9 Attachment A: State Early Childhood Education Scholarships Verification form for families that are eligible for one of the public programs named in section II of the scholarship application but do not have an eligibility letter. Children who are eligible for one of the programs below are also eligible for a State Early Childhood Education Scholarship Parent/legal guardian complete this section _ (parent/legal guardian name) is applying for a state early childhood education scholarship for (name of child or children) Professional with publicly funded program please complete and sign this section 1) I verify that the child or children listed above are enrolled in at least ONE of the following programs. (Please check the name of the program or programs for which you are aware that the child is eligible). Minnesota Family Investment Program (MFIP) Child Care Assistance Program (CCAP) Food Support (SNAP) Free and Reduced Price Lunch Program Child and Adult Care Food Program (CACFP) Day Care Center Child/Children Eligible for Free (A) or Reduced (B) meal reimbursement Family Day Care Home Family Income Eligible Tier I (Sponsoring Organization to Verify) Head Start Foster care Food Distribution Program on Indian Reservations 2) Professional s information: Employer/name of business Employer/name of business address Work phone number I certify (promise) that the information provided on this form is true. Signature Date Printed name 9

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