Fillable Form 22201: ARMY RESPITE CHILD CARE PARENT APPLICATION (Child Care Aware)

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Form 22201: ARMY RESPITE CHILD CARE PARENT APPLICATION (Child Care Aware)

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  • 37 check-boxes
  • 110 other fields

Country of origin: US
File type: PDF

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M
ili
t
a
r
y
Fee
A
ss
i
s
t
a
n
c
e
D
e
p
a
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t
m
e
n
t
1515
N. Courthouse Road, 2
nd
F
l
oo
r
A
r
li
n
g
t
o
n
,
VA
22201
1-800-424-2246
ARMY RESPITE CHILD CARE
PARENT APPLICATION
P
l
e
a
se
c
o
m
p
l
e
t
e
t
h
i
s
a
pp
li
ca
t
i
o
n
and fax to
703-341-4169
or
e
m
a
il
t
o
armyrespitechildcare@usa.childcareaware.org
S
E
C
T
I
O
N
A
–
RE
S
P
I
T
E
CHILD
C
A
RE
PROGRAM
N
EE
D
S
ENROLLMENT
S
T
A
T
U
S
:
(Check one)
1. I am
a
l
r
e
a
dy
e
n
r
o
ll
e
d
in
a
Child
Care
Aware® of
A
m
e
r
i
c
a
-o
p
e
r
a
t
e
d
f
ee
a
ss
i
s
t
a
n
c
e
program
(e.g., O
M
CC
,
MCCYN) and I want to
r
e
g
i
s
t
e
r
for Army
R
es
p
i
t
e
Child
Care.
2. I am not
c
u
rr
e
n
t
l
y
e
n
r
o
ll
e
d
in
a
Child
Care
Aware® of
A
m
e
r
i
c
a
-o
p
e
r
a
t
e
d
f
ee
a
ss
i
s
t
a
n
c
e
program; I
o
n
l
y
want to
r
e
g
i
s
t
e
r
for Army
R
es
p
i
t
e
Child
Care.
3. I am
updating
or
r
e
n
e
w
i
n
g
an
e
a
r
li
e
r
Army
R
es
p
i
t
e
Child
Care
a
pp
li
ca
t
i
o
n
with
a new
p
r
o
v
i
d
e
r
.
4. I am not
c
u
rr
e
n
t
l
y
e
n
r
o
ll
e
d
in
a
Child
Care
Aware® of
A
m
e
r
i
c
a
-o
p
e
r
a
t
e
d
f
ee
a
ss
i
s
t
a
n
c
e
program; I want
t
o
r
e
g
i
s
t
e
r
for
f
u
ll
-
t
i
m
e
or
p
a
r
t
-
t
i
m
e
f
ee
a
ss
i
s
t
a
n
c
e
and
R
es
p
i
t
e
Child
Care.
ELIGIBILITY
S
T
A
T
U
S
:
(Proof of status
r
e
q
u
i
r
e
d
)
(Check one)
1. I am Deployed: Contingency Operations
2. I am assigned to a Warrior in Transition Unit (WTU).
3. I am Deployed: Rotational Forces
.
4. I am Deployed: Non-Contingency Operations
E
ff
e
c
t
i
v
e
date of
m
ili
t
a
r
y
orders:
FROM: TO:
CHECK O
N
E
:
I am the Parent: I am the Non-Parent
L
e
g
a
l
G
u
a
r
d
i
a
n
:
S
E
C
T
I
O
N
B
–
H
O
U
S
E
H
O
L
D
I
N
F
O
R
M
A
T
I
O
N
S
ER
V
I
C
E
M
E
M
BER
’
S
CONTACT
I
N
F
O
R
M
A
T
I
O
N
:
Mandatory Documents:
M
ili
t
a
r
y
Orders, Child(ren)’s
Birth
C
e
rt
i
f
i
ca
t
e
(
s
), and
D e pl oy me nt V er if i ca tio n F or m
Fa
m
il
y
I
D#
(
I
f
applicable
):
/
/
S
p
o
n
s
o
r
Last
Name
S
p
o
n
s
o
r
F
i
r
s
t
Name M.I.
S
p
o
n
s
o
r
Date of
B
i
r
t
h
( ) - ( ) - ( )
-
G
r
a
d
e
Duty
T
e
l
e
p
h
o
n
e
Home
T
e
l
e
p
h
o
n
e
C
e
ll
Phone
S
t
r
ee
t
N
a
m
e
a
n
d
N
u
m
b
e
r
:
City
S
t
a
t
e
Zip
Code
V
a
li
d
E
m
a
il
A
dd
r
ess
:
(
W
ill
b
e
u
s
e
d
f
or
a
ll
c
o
mm
u
n
i
ca
t
i
o
n
)
A
l
t
e
r
n
a
t
e
e
m
a
il
a
dd
r
ess
:
SECTION C – SERVICE MEMBER’S SPOUSE/SECOND PARENT
C1. SERVICE MEMBER SPOUSE CONTACT INFORMATION:
/
/
Last Name First Name M.I. Date of Birth
(
_)
-
(
)
-
Grade Telephone # Home Telephone #
Street Name and Number
City State Zip Code
Email
Address:
C2. LEGAL GUARDIAN CONTACT INFORMATION (IF APPLICABLE):
/
/
Last Name First Name M.I. Date of Birth
(
)
-
(
_)
-
Duty Telephone # Home Telephone #
Street Name and Number
City State Zip Code
Email
Address:
S
E
C
T
I
O
N
D –
CHILD
C
A
RE
PROVIDER
I
N
F
O
R
M
A
T
I
O
N
FIRST PROVIDER:
I
a
m
a
l
r
e
a
dy
e
n
r
o
ll
e
d
i
n
A
r
m
y
F
ee
A
ss
i
s
t
a
n
ce
a
n
d
w
a
n
t
t
o
u
se
m
y
c
u
rr
e
n
t
p
r
o
v
i
d
e
r
.
P
r
o
v
i
d
e
r
I
D
#
Provider/Program Name:
(As
it
appears
on
li
c
e
n
se
/
r
e
g
i
s
tr
a
t
i
o
n
)
Provider/Program Address (please indicate the address where care is provided):
Street Name and Number City State Zip Code
Provider Phone Number: _____________________________ Provider Email: _______________________________________
S
E
C
O
N
D
PROVIDER
(if
needed):
Provider/Program Name:
(As
it
appears
on
li
c
e
n
se
/
r
e
g
i
s
tr
a
t
i
o
n
)
Provider/Program Address (please indicate the address where care is provided):
Street Name and Number City State Zip Code
Provider Phone Number: _____________________________ Provider Email: _______________________________________
THIRD
PROVIDER
(if
needed):
Provider/Program Name:
(As
it
appears
on
li
c
e
n
se
/
r
e
g
i
s
tr
a
t
i
o
n
)
Provider/Program Address (please indicate the address where care is provided):
Street Name and Number City State Zip Code
Provider Phone Number: _____________________________ Provider Email: _______________________________________
SECTION E –
C
H
I
LD
R
E
N
WHO WILL
N
EE
D
R
E
SP
I
T
E
C
H
I
LD
C
A
R
E
NA
M
E
S
OF CHILD(REN) TO BE CARED FOR THROUGH THE ARMY
RE
S
P
I
T
E
CARE
PROGRAM:
F
u
l
l
N
m
e
o
f
C
h
i
l
d
(
F
i
r
s
t
nd
L
as
t
N
m
e
)
Da
t
e
o
f
B
i
r
t
h
G
e
n
d
e
r
(
M
/
F
)
Co
mm
e
n
t
.
.
.
.
5.
6.
PARENT/LEGAL GUARDIAN RESPITE CARE CERTIFICATION: (Please read carefully, check all boxes, sign and date in designated
area.)
I CERTIFY THAT:
□
I am the parent or legal guardian of the child(ren) listed and I may be required to submit proof of such in order to receive fee assistance.
□
All information submitted in this application is true and correct. Any misrepresentation of this information may result in reclaiming any money paid for
child care and may result in prosecution under applicable State and Federal laws. See 18 U.S.C. § 1001.
I
UNDERSTAND
THAT:
□
I must submit proof of my continued eligibility for this program when requested.
□
This information is being given in connection with military funds used to pay for the cost of Army Respite Care, and Military and Child Care Aware® of
America (CCAoA) officials may verify any information on this application at any time they deem necessary.
□
This program is not an entitlement program and is subject to the availability of funds, which may be discontinued at any time.
□
All program policies and guidelines are set forth by the funding entity’s requirements, including but not limited to sponsor status, provider eligibility,
schedule of care, number of hours of care, and more. CCAoA serves only as the program administrator. If I do not meet the minimum requirements set
forth by the funding entity, then I am not eligible for the program.
□
Respite Care fee assistance for which I am eligible is based on my program eligibility, , age of child(ren), the provider/program’s location, if there are any
changes to my situation, I must make CCAoA aware of those changes immediately.
□
Both parents’/legal guardians’ information must be listed on the application unless I am a single parent with sole custody.
□
I must select a qualified child care provider/program that meets my program’s requirements in order to participate in the Army Respite Child Care
Program. These requirements include but are not limited to: a state license and an inspection report free of disqualifying incidents. Programs/providers
who do not meet the eligibility requirements of my program and who are not qualified for my program will not be reimbursed. For more information on
provider eligibility, please visit http://usa.childcareaware.org/.
□
A provider/program’s probation or disqualification from the Army Respite Child Care Program may result due to severe non-compliances or a change in
the provider/program’s state licensing status. Respite Care payments will not be issued to providers/programs who are disqualified. In order to continue
with the Army Respite Child Care Program, I must choose a new eligible provider.
□
I must give CCAoA a minimum of two (2) weeks’ notice prior to changing child care providers/programs by submitting a CHANGE OF
PROVIDER/PROGRAM FORM. I may not change providers more than three (3) times per year.
□
I may use more than one provider; however, CCAoA will not reimburse more than one provider/program for the same period of time, for the same child.
□
If I use a back-up child care provider/program, CCAoA must reimburse the primary child care provider/program first.
□
I must disclose any income and additional sources of fee assistance, including but not limited to:; other federal/state benefits;; child care/fee assistance
vouchers, waivers, or subsidies; state/private child care subsidies; state/private child care scholarships; anything else of value, even if not taxable, that
was received for providing services or to help pay for child care services.
□
I must submit a copy of the Statement of Non-Availability with my application packet when requested. If I reside within 15mi/20min form any
installation or garrison, the Statement of Non-Availability must be signed by the authorized CYSS representative at that installation or garrison. The
following are exempt: school age children, geographically dispersed Army National Guard & Army Reserves, Wounded Warriors, and SOS sponsors.
□
I may not claim reimbursement for more than my Eligibility Status (indicated on page 1 of the Army Respite Child Care Application) allows per child per
month of the Army Respite Child Care Program.
□
I may not receive funds, subsidies, or fee assistance from both military-sponsored child care and the Army Respite Child Care Program at the same time.
□
All child care rates reported to CCAoA for respite calculation purposes must include any offered discounts and/or promotions. These discounts must be
reported and applied up front at the time of processing.
□
CCAoA will only make payments directly to the child care provider/program and not to me.
□
The Respite Care subsidy covers hourly care for children up to a specific hourly provider rate cap for each child. I am responsible for any remaining child
care fees over the provider rate cap. For more information, see http://usa.childcareaware.org/fee-assistancerespite/military-families/army/#programs
□
I am responsible for any remaining child care fees after Army Respite Care fee assistance has been issued. CCAoA may not pay the full cost of child care
for approved families. Payment arrangements for the remaining fees must be made directly with my provider/program and not CCAoA.
□
Attendance sheets must be completed, signed by the parent/legal guardian and child care provider, and submitted to CCAoA within 30 days of services
provided. Failure to submit attendance sheets within this timeframe will result in forfeiture of payment. For more information on Payment Policies,
please visit http://usa.childcareaware.org/.
□
The first and last month payments may be prorated based on the hours of respite care used per month per child.
□
Fee assistance will not be backdated to any time before I submitted my application, regardless of whether my child was already in care.
□
I must complete my application or recertification within 90 days in order to be eligible for backdated fee assistance. If deemed eligible for backdated
payments, I must submit the attendance sheets within 30 days of when I receive my fee assistance approval.
□
I must notify CCAoA at least fifteen (15) calendar days before ending child care services. In cases of emergency, I will notify CCAoA immediately (1-800-
793-0324).
□
I have read all of the above and understand its content. I also understand that non-compliance with any of the above may result in immediate termination of my respite
care and of my participation in the Army Respite Child Care Program and I may be required to re-pay any money paid on my behalf.
/
/
Parent/Legal Guardian (please print) Parent/Legal Guardian Signature Date
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Form 22201: ARMY RESPITE CHILD CARE PARENT APPLICATION (Child Care Aware)

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Completed 20 January 2021

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