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Chitimacha Tribe of Louisiana (Chitimacha Tribe of Louisiana)

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Chitimacha
Tribe of Louisiana
CCDF Application
CHITIMACHA TRIBE OF LOUISIANA
CHILD CARE AND DEVELOPMENT FUND PROGRAM
3231 Chitimacha Trail
P.O. BOX 520
CHARENTON, LA 70523
APPLICATION FOR SERVICES
To the Applicant:
Complete each question on this application to the best of your knowledge and
ability. If you have any questions while you are completing the application, ask for
assistance from Ida Borel, CCDF Program Manager. She can be contacted via any
of the following: 3231 Chitimacha Trail, P.O. Box 520, Charenton, LA 70523, e-
mail: idab@chitimacha.gov
, Office Phone: (337)923-7000, Fax: (337)923-2475.
Complete this application in blue or black ink only. Do not write over, erase, or use
correction fluid. If you make a mistake draw one straight line through the incorrect
answer. Insert the correct answer clearly and initial the correction.
Please attach all required documentation listed below, as they relate to you, to the
CCDF application:
Proof of Income (for the last month for household members)
Proof of School Verification for Parent/Guardian
Proof of Guardianship/Protective Services Documents (if applicable)
Proof of Adoption (if applicable)
Special Needs Documentation for child(ren)
A detailed listing of acceptable forms of documentation can be found on the
following page.
As a reminder, applications will not be processed until all required
documentation is submitted.
REQUIRED VERIFICATION DOCUMENTATION
Eligibility will be determined based upon the information that you provide. All
required documentation must show applicant(s) full name.
If you are unable to obtain any of the following documents or have any other
questions, please contact Ida Borel.
Proof of Income
Applicant must verify family income for one
(1) month.
a. Payroll Check Stubs (most recent)
b. W-2
c. Income Tax Return
d. Certified Letter from Employer (must
state hourly/wage information and
must be signed by an authorized
representative of the company)
School Attendance Verification
Applicant must verify that they are attending
school.
a. Verifiable class schedule/school
registration
Proof of Guardianship/Protective Services
Applicant must provide certified legal
documentation appointing he/she as
legal
guardian or “in loco parentis”.
Proof of Adoption
If applicant or spouse is not the natural
parent, as indicated on the birth certificate,
the applicant must provide certified legal
proof of adoption documentation.
Special Needs Documentation
Documentation in support of special needs
must be submitted.
a.
Doctor's report
b.
School Records (i.e., school counselor,
school psychologist)
3231 Chitimacha Trail P.O. Box 520 Charenton, LA 70523 (337) 923-7000 Fax (337) 923-7791
CHITIMACHA
TRIBE OF LOUISIANA
Application Form
Parent/Guardian Information # 1
Please complete all applicable fields below.
Are you currently enrolled in any type of educational program?
☐ Yes ☐ No
Are you currently employed or attending job training?
☐ Yes ☐ No
Date Received
☐Initial Application ☐Renewal
First
MI
DOB (mm/dd/yyyy)
Tribal Affiliation
Mailing Address
City
State
Zip
Physical Address
City
state
Zip
Phone
Phone 2
Email
School:
Phone
Fax
Address
City
State
Zip
Classification
☐Part-Time ☐ Full-Time
Schedule: Hours Per Day
Schedule: Days Per Week
Employer:
Phone
Fax
Address
City
State
Zip
Monthly Gross Wages
☐ Part-Time ☐ Full-Time
Schedule: Hours Per Day
Schedule: Days Per Week
Page 2
*Please complete information on page 2 for Parent/Guardian/Others who are residing in the same
household as the child(ren) in need of care.
Parent/Guardian/Other Information #2
Please complete all applicable fields below.
Are you currently enrolled in any type of educational program?
☐ Yes ☐ No
Are you currently employed or attending job training?
☐ Yes ☐ No
Last
First
MI
DOB (mm/dd/yyyy)
Tribal Affiliation
Phone
Phone 2
Email
School:
Phone
Fax
Address
City
State
Zip
Classification
☐Part-Time ☐ Full-Time
Schedule: Hours Per Day
Schedule: Days Per Week
Employer:
Phone
Fax
Address
City
State
Zip
Monthly Gross Wages
☐ Part-Time ☐ Full-Time
Schedule: Hours Per Day
Schedule: Days Per Week
Page 3
LIST ALL INDIVIDUALS RESIDING IN THE HOUSEHOLD
Protective Services
Are any of the child(ren) listed above in Protective Services?
☐Yes ☐ No
1.________________________________ 2.________________________________
Special Needs
Please list if any above child(ren) have disabilities.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Assurances Section
1.) I affirm, to the best of my knowledge, that the information on this application form is true, correct, and complete.
2.) I will notify the agency within ten (10) working days when there is any change in my household income, family size, or
need status.
3.) I understand that I am responsible for directly paying the provider for the non-subsidized portion of the childcare
services.
4.) I understand that I must renew my eligibility annually and that my failure to do so will constitute grounds for termination
from the CCDF Program.
_____________________________ _______________
Parent/Guardian Date
_____________________________ _______________
Parent/Guardian Date
Names
Date of Birth
(mm/dd/yyyy)
Care Needed?
Program
(Check all that apply)
Parent / Guardian
N/A
Parent / Guardian
N/A
☐ Yes ☐ No
☐ Yaamahana ☐ Summer Camp ☐ After School Care
☐ Yes ☐ No
☐ Yaamahana ☐ Summer Camp ☐ After School Care
☐ Yes ☐ No
☐ Yaamahana ☐ Summer Camp ☐ After School Care
☐ Yes ☐ No
☐ Yaamahana ☐ Summer Camp ☐ After School Care
☐ Yes ☐ No
☐ Yaamahana ☐ Summer Camp ☐ After School Care
☐ Yes ☐ No
☐ Yaamahana ☐ Summer Camp ☐ After School Care
Page 4
Provider Information Page
Name of Center: ☐ Yaamahana ☐ Summer Camp ☐ After School Care
Name of Child:____________________________
Approved Attendance Schedule
Effective Date of Care:
Monday
Tuesday
Wednesday
Thursday
Friday
Hours in
Care:
Total Hours Per Week:
Total Days Per Week:
Rate Per Week:
Page 5
Program Manager Certification
Name of Child:______________________________________
Household Income (Monthly)
Family Size:___________ Total Monthly Household Income:____________
Next Review Date: ______________________
Additional Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________ ________________
Program Manager Date
_____________________________________ ________________
Administrator Date
Effective Date of Care:
Last Date of Care:
Parent/Guardian 1
Parent/Guardian 2
10% Deduction
Total
Wages:
Other:
Total Weekly Tuition:
Parent Pays:
CCDF Pays:
%
☐
Eligible
☐
Not Eligible
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Completed 27 January 2021

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