White Earth Early Learning Scholarship Program Information about the program Household Size Gross income How to complete the application:

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1 White Earth Early Learning Scholarship Program White Earth Child Care/Early Childhood Programs Funded by MN s Race to the Top Early Learning Challenge Grant Information about the program Use this application to apply for the White Earth Early Learning Scholarship 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 who are chosen by the parent or legal guardian. The child receiving the scholarship must attend the program a minimum of 15 hours per week and the program must be participating in the MN Parent Aware Quality Rating and Improvement System. If you receive funding for child care through CCAP or White Earth Child Care Assistance Program, you are also eligible for the White Earth Early Learning (WEEL) Scholarship program. If you pick an approved program, you can use the WEEL Scholarship to pay for parent charges or fees that are not covered by the assistance program. To qualify, your family must meet the following requirements: 1) Your family must reside on the White Earth Reservation 2) Your family must have a gross income at or below 200% of the Federal Poverty Rate Household Size Gross income 2 $30,260 3 $38,180 4 $46,100 5 $54,020 6 $61,940 7 $69,860 8 $77,780 For each additional person add $ 7,920 Based on 2012 Annual Federal Poverty Guidelines 3) You must have one or more children between the ages of birth and 5 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 birth and 5 years old who are not yet eligible to attend kindergarten. 5) Willingness to participate in child development education and parent mentor program (see attachment A). 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 application to: White Earth Child Care/Early Childhood Program Attn: Mary Metelak P.O. Box County Hwy. 34 White Earth, MN What happen next? The Application will be processed and we will contact you to let you know if your 1 child or children qualify for an Early Learning Scholarship. If you have questions, contact the scholarship administrator at ext or ext

2 Section I. Demographic Information: (Please print) Applicant Name (Last, First, MI) Other Names Used Date of Birth Co-Applicant Name (Last, First, MI) Other Names Used Date of Birth Street Address City State & Zip Mailing Address (If different than Street Address) City State & Zip County Home Phone Cell Phone Work/Other Phone Address Enrolled Tribal Member or Descendent of White Earth Reservation Yes No If Yes Enrollment # White Earth Child Care Early Childhood Program(s) you participate in: (check all that apply): Child Care Assistance Child Care Licensing Early Learning Scholarship Parent Mentor Program FFN Program Early Learning Center Intake Staff Member: Household Information List all household members including applicant. Name (Last, First, MI) Relationship to Applicant Social Security # D.O.B. Gender SELF Currently a Student (list grade) Diagnosed Special Need Yes/No Directions to Home 2

3 Applicant Ethnicity American Indian or Alaska Native Asian Native Hawaiian or other Pacific Islander Black or African-American White Hispanic or Latina Level of Education No Diploma High School or GED Some College (no degree) Vocational/Certification Associate s degree Bachelor s degree Master s degree Additional Information - please check boxes that pertain to you Teen Parent Need Interpreter Homeless Unemployed Married Single One Parent Single Two Parent Section II. Income Eligibility Verification Option 1: You can provide proof that you or your children are eligible for a publicly funded program or Option 2: You can list your income and attach proof of this income. ***Eligibility Option 1*** 1) Are you or your child, ages birth to kindergarten entry, currently identified as eligible for one of the following programs? Check any that apply. Minnesota Family Investment Program (MFIP) Child Care Assistance Program County Child Care Assistance Program White Earth Child Care/Early Childhood Program Head Start Foster Care Free and Reduced Price Lunch Program Food Distribution Program on Indian Reservations 2) Proof of eligibility. If you or your child(ren) are eligible for any of the programs listed above, you must attach written documentation showing eligibility for ONE of the programs and fill out Attachment B (page 10). ***Eligibility Option 2*** 1. Parent/legal guardian income. Fill out Attachment C (page 11). List all sources of income received by you and any other of your children s parents or legal guardians who have lived in your household for the past 6 months. Write in each gross income before deductions (not take-home pay) from all jobs and other sources of income. 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

4 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 for whom 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. Section III. Early Childhood Education Program Choice You may use your White Earth Early Learning 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 MN Parent Aware Quality Rating and Improvement System. Parent Aware is a rating tool for selecting high quality child care and early education. For more information about Parent Aware go to 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: Parent Aware Rating Scholarship amount per child 4 Star Program Up to $13,000 per child 3 Star Program Up to $11,000 per child 2 Star Program Up to $7,000 per child 1 Star Program Up to $5,000 per child Signed up for Parent Aware but haven t received a rating. Up to $4,000 per child Payment rates are based on the number of hours a child is in an ECE Program with a minimum of 15 hours per week. The number of hours eligible for scholarship funds will be determined when the scholarship is awarded. 4

5 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 Name: Program Name: Program Address Program Phone # Parent Aware Rating (select one) 4 Star 3 Star 2 Star 1 Star In Process Don t know Rate per Hour Daily Weekly Monthly No Charge $ Days child will be attending program (circle all that apply) M T W TH F SA S Hours of Care to Check if child is currently in this program Child Name: Program Name: Program Address Program Phone # Parent Aware Rating (select one) 4 Star 3 Star 2 Star 1 Star In Process Don t know Rate per Hour Daily Weekly Monthly No Charge $ Days child will be attending program (circle all that apply) M T W TH F SA S Hours of Care to Check if child is currently in this program **Children qualifying for the scholarship program must be charged the same tuition rates as other children in the program. Scholarship funds must be used to supplement not supplant any Federal, State or local funds. Scholarship tuition payment covers the gap between the CCAP payments and full tuition (including family copayments, scholarship fees, transportation costs, registration fees, and activity fees). No/Not sure. If your child is found eligible for a WEEL Scholarship, your WEEL Scholarship Coordinator and or Parent Mentor will help you choose a program. If your child is currently attending a program but you would like to explore other options, your WEEL Scholarship Coordinator 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 the White Earth Early Learning (WEEL) Scholarship Program. 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 to White Earth Child Care/Early Childhood Program administrative staff to share information about my application for the WEEL Scholarship, my eligibility for and the amount of any WEEL 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 WEEL Scholarship and to allow the WEEL Scholarship to be paid to the program on my behalf. Printed name of parent/legal guardian Signature of parent/legal guardian Date Release of information for evaluation/consent to participate in evaluation I give my consent for White Earth Child Care/Early Childhood Program staff to share my information with the entity chosen by the Minnesota Department of Education (MDE) to evaluate the White Earth Early Learning (WEEL) Scholarship Program. I understand that my information must be shared so that MDE can evaluate the WEEL Scholarship Program. I understand that the evaluation will analyze how ECE Scholarship Funds are spent, how families are informed about the Scholarship program, and how the child s development has been impacted. 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 a White Earth Early Learning Scholarship. Printed name of parent/legal guardian Signature of parent/legal guardian Date 6

7 Minnesota Department of Education White Earth Early Learning (WEEL) Scholarships Program Tennessen Warning What information are we requesting? We are requesting all information on the White Earth Early Learning (WEEL) 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 WEEL Scholarships program. We will use the information collected via this application or any additional communications related to this application to determine eligibility for the WEEL Scholarships program. This information is also necessary to comply with the state law authorizing the WEEL Scholarships program through the MN Department of Education. 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 WEEL Scholarships program. Who else may see this information? A third-party entity will evaluate the effectiveness of the WEEL 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. 7

8 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 8

9 Attachment A White Earth Early Learning Scholarships Family Participation Agreement In order to be eligible to receive a White Earth Early Learning Scholarship, the parent/legal guardian must agree to the following: Enroll child(ren) in a Parent Aware rated Early Childhood Education (ECE) program a minimum of 15 hours per week. Participate in parent mentoring component of White Earth Early Learning Scholarship Program. What is parent mentoring? Parent mentors will visit the homes of enrolled families beginning at birth until children enter kindergarten. The primary goal of parent mentoring is that each participating parent/caregiver is provided with information necessary to select a high quality ECE program and be involved in the program s activities and child s education. Secondary goals of parent mentoring include the following: 1)ensuring that parents have skills and knowledge necessary to promote school readiness throughout their child s early years (birth to 5); and 2) ensuring that parents have access to community resource to support their family s education and health needs. Parent mentors will visit families an average of once a month with learning tools, resources, and tips for parents to use with their children. Parents will receive Caring for Kid Store points for every home visit. Attend free training (minimum of 2 trainings per year) on child development/early childhood issues (Caring for Kids Store points will be given for each training attended). Understand that they will be given the opportunity to have my child participate in early childhood screening at age three. Reside on the White Earth Indian Reservation. Give the ECE program a two week notice if the family moves or decides to transfer a child to another program. Agree to participate in State and White Earth Child Care/Early Childhood Program data collection pertaining to Race to the Top Early Learning Challenge Scholarship funds. I have read, understand, and agree with the information stated above. Parent/Legal Guardian Parent/Legal Guardian Scholarship Administrator 9 Date Date Date

10 Attachment B Income Verification ***Eligibility Option 1*** This form will serve as the verification form for families that are eligible for one of the public programs named in section II of the scholarship application. Children who are eligible for one of the programs below are also eligible for a White Earth Early Learning Scholarship. Parent/legal guardian complete this section (parent/legal guardian name) am applying for the White Earth Early Learning Scholarship Program for (name of child or children). I give my permission to the Agency listed below to release information verifying participation in the program. Signature of Applicant Date Professional with publicly funded program completes and signs 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 County Child Care Assistance Program White Earth Child Care/Early Childhood Program Head Start Foster Care Free and Reduced Price Lunch Program Food Distribution Program on Indian Reservations Employer/name of business Employer/name of business address Work phone number address: I certify (promise) that the information provided on this form is true. Printed name Signature Date 10

11 Attachment C Income Verification ***Eligibility Option 2*** Please use this worksheet to calculate your total family income. EARNED INCOME (Wages and profits for the parent(s) or guardian(s) of child(ren) listed in this application) Write in gross income before deductions (not take-home pay). Indicate how often each income is received: weekly, bi-weekly (every other week), semi-monthly (twice per month), monthly or other. Do not write in hourly wage. For farm or self-employment income only, list net income (after deductions). Attach additional page if needed. Parent/Guardian Name Employer s Name Gross Income TOTAL EARNED INCOME How often are you paid? Weekly Bi-Weekly Semi-monthly Monthly Other Weekly Bi-Weekly Semi-monthly Monthly Other Weekly Bi-Weekly Semi-monthly Monthly Other Annual Amount (to be calculated by WECC Staff) UNEARNED INCOME (For the parent(s) or guardian(s) of child(ren) listed in this application) Yes No How often do you Amount Received Type (circle those that apply) receive payments? Pension, SSI, Retirement, Social Security Public Assistance, Child Support, Alimony Unemployment, Worker s Compensation TOTAL ANNUAL UNEARNED INCOME: has applied for services through the White Earth Child Care/Early Childhood Program and must have verification of income for eligibility. He or she certifies that the source(s) stated above is their current gross income. The signature below authorizes release of any income related information. Signature of Applicant Date ****************************************************************************************** Employer Verification of Income Employer Name : Is this person currently receiving the income stated above $ per Signature of Authorized Official Title Date 11