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HO-CHUNK NATION COMMUNITY SUPPORTIVE SERVICES
Division of Ho-Chunk Nation Social Services
CHILD CARE ASSISTANCE
PROGRAM
PARENT/GUARDIAN
MANUAL
Phone: 715-284-2622 ext. 5148
Fax: 715-284-9486
808 Red Iron Rd
P.O. Box 40
Black River Falls, WI. 54615
October 1, 2020 - September 30, 2022
Updated: August 2019
CHILD CARE ASSISTANCE PROGRAM
10/01/2019
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Table of Contents
Mission Statement ........................................................................................................ 4
Administration ............................................................................................................. 4
Services Offered ......................................................................................................... 4-5
Special Needs ................................................................................................................ 5
Protective Services/Temporary Placement/Guardianship ............................................. 5
Transition from Temporary Placement/Guardianship to Permanent ............................ 6
Eligibility Requirements for Parent(s)/Guardian(s) ................................................... 6-7
End of Employment/End of Educational Program/Loss of Child Care ........................... 7
Hours of Subsidized Care Allowable Weekly ................................................................. 7
Absences ....................................................................................................................... 7
Maternity Leave ............................................................................................................ 8
Newborns ..................................................................................................................... 8
Eligibility Requirements for Children ........................................................................... 8
Definition of Household ............................................................................................. 8-9
Combining Households ................................................................................................. 9
Divorce ......................................................................................................................... 9
Definition of Income ..................................................................................................... 9
Assets.......................................................................................................................... 10
Co-Payment ................................................................................................................ 10
Receipt of Provider’s Policy Handbook ....................................................................... 10
Reporting Change ....................................................................................................... 10
Fraud .......................................................................................................................... 10
Fees Covered Under the Program ................................................................................ 10
Fees NOT Covered Under the Program ......................................................................... 11
Required Documents for a Complete Application .................................................... 11-12
Decision of Eligibility ................................................................................................... 13
Waitlist Eligibility ........................................................................................................ 13
Approved Application ............................................................................................. 13-14
Eligibility & Review Process .........................................................................................14
Youngstar ....................................................................................................................14
Appeal Process ............................................................................................................. 15
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Table of Contents
Appendix .....................................................................................................................16
Application Completion Checklist ................................................................................ 17
Child Care Assistance Application .......................................................................... 18-22
Parent/Guardian Policy Handbook Receipt ................................................................. 23
Discharge Policy ......................................................................................................... 24
Voucher Policy ............................................................................................................ 25
Release of Information ............................................................................................... 26
Eligibility of Enrollment Form .................................................................................... 27
Co-Payment Schedule ................................................................................................. 28
Job Search Form ......................................................................................................... 29
Resource Request Form .............................................................................................. 30
Complaint Form ........................................................................................................... 31
CHILD CARE ASSISTANCE PROGRAM
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MISSION STATEMENT
To subsidize childcare costs for our Ho-Chunk Children.
ADMINISTRATION
This policy Manual follows the guidelines as outlined in the Child Care Development Fund (CCDF) block
grant, which is received through the Administration for Children and Families in Washington DC. The CCDF
Grant funding years begins October 1
st
through September 30
th
each year. Since grant and supplemental Net
Profit Distribution (NPD) funds are limited – funds are obligated on a first come first serve basis to our
families with the exception of Protective Services, Temporary Custody and Special Needs children. If all
funding sources have been obligated, applicants will be placed on a waiting list until an there is an opening for
assistance.
It is a requirement as part of the parent(s)/guardian(s) application process that they apply through the
state/county of residence for child care assistance. Applications are accepted regardless of approval or denial of
assistance as long as they carried out all the eligibility requirements. The Child Care Assistance Program
(CCAP) require our parent(s)/guardian(s) to utilize all sources of funding. Policies can change without notice if
deemed necessary for the integrity of the program.
It is a requirement that the parent(s)/guardian(s) are current on all financial obligations with their child care
provider before acceptance into CCAP.
The Child Care Assistance Program is designed to assist Ho-Chunk families using CCDF grant funds to
subsidize child care costs for their tribally enrolled or enrollable children residing in the following counties:
Clark
Columbia
Crawford
Dane
Eau Claire
Juneau
La Crosse
Marathon
Sauk
Shawano
Vernon
Wood
OTHER WISCONSIN COUNTIES/OUT OF STATE
Net Profit Distribution (NPD) funding is on a first come first serve basis until all funds are obligated. Funds are
limited and are first come first serve basis.
SERVICES OFFERED
The Child Care Assistance Program (CCAP) provides financial assistance to our parent(s)/guardian(s) for child
care expenses. The program operates on a voucher system with payment going directly to the child care
providers.
Child Care Center Requirements – Only State licensed, State Certified and Faith Based Centers that
follow the Wisconsin Model of Early Learning Standards (WMELS) https://dpi.wi.gov/early-
childhood/practice. Boys & Girls Clubs, YMCA’s and YWCA’s are acceptable if they comply with state
health and safety standards. No camps, day camps, tuitions, etc.
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Parent(s)/Guardian(s)/ Requirements – Parent(s)/Guardian(s) Must be attending an education
program with a minimum of ¾ status (ex. 9 credits) or working at least 35 hours per week. A
combination of each is acceptable with education programs part time (ex. 6 credits) and working a
minimum of 24 hours weekly. Parent/Guardian attending an inpatient or outpatient drug or alcohol
rehabilitation program (must provide proof).
Income Requirements – Parent(s) gross income cannot exceed the income guidelines as established
through CCAP. Per Capita IS NOT included as income. (See Fee Scale located in Appendix)
Child Requirements – Child must be an enrolled or eligible to be enrolled as a Ho-Chunk tribal
member. Children have a one year grace period to become enrolled through the Ho-Chunk Nation.
SPECIAL NEEDS
Priority Services are given to children with Special Needs as program funding is available.
All program requirements apply.
Documentation Required:
Documentation from a qualified professional; a physician, psychologist, special educator, or other qualified
health care professional that has diagnosed the child with a special need. To be prioritized in the program as
special needs, the diagnosis must show the child has needs beyond the basic care given in the child care center
and the daily care given for the child will be modified to accommodate said needs.
PROTECTIVE SERVICES, TEMPORARY PLACEMENT/GUARDIANSHIP
Priority services are given to families with children who are considered vulnerable, in protective services or
temporary placement/guardianship dependent on funding availability.
Appropriate documentation is required and include:
1. Indian Child Welfare; Wards of the Ho-Chunk Nation (placement) or families with Temporary
Guardianship.
2. Referrals through a tribal or county social services agency.
3. Homeless circumstances, crisis and/or harmful situations; which also includes Respite Care.
4. Referrals from other tribal or non-tribal Human Services Professionals for children vulnerable of a
health or social condition. (Parents working to assimilate into society after incarceration by obtaining
employment/education, etc.)
5. “Authorization Form-Placement Parent” from your Ho-Chunk Nation assigned Social/Case Worker
6. Legal court documents
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TRANSITION FROM TEMPORARY PLACEMENT/GUARDIANSHIP TO
PERMANENT GUARDIANSHIP:
Once a family becomes a child’s Permanent Guardian, the biological parent’s rights of that child are terminated
and the Guardian’s assume the legal parental rights of the child until the age of 18. Once Permanent
Guardianship is official, all program guidelines apply, including income guidelines and co-payments.
Legal court documents are required to be submitted within 5 business days of any change in
Placement/Guardianship.
Families are required to complete a new application during this transition.
Once notice has been communicated to the Child Care Assistance Program Manager, a 30-day grace period is
given so families can maintain child care assistance and submit any additional documentation that may be
required. At that time the Program Manager will review the participants file to assess eligibility.
Maximum subsidized care cannot exceed 50 hours per week without prior approval from the CCAP
Manager.
ELIGIBILITY REQUIREMENTS AND/OR ALLOWABLE ACTIVITIES FOR
PARENT(S)/GUARDIAN(S)
Parent(s)/Guardian(s) must meet the criteria defined below to be considered for assistance:
Definition of Employment:
• Permanent Full-time employment of a minimum of 35 hours weekly.
• Contracted Limited Term Employee (LTE) with a minimum of 35 hours weekly.
• Actively participating in either the 477 or W2 Programs (must provide proof of enrollment)
• The 3 month job search is now allowable upon entry of program. The job search is limited to a one time
occurrence per household within a 12 month period.
Participants who are unemployed, in the 477 or W2 programs, are required to complete and submit the Job
Search Form that is found in the appendix of the application.
A minimum of 8 job searches per month must be completed and the job search form must be submitted to the
CCAP Manager for continual participation in CCAP.
**Failure to complete and submit will result in suspension from program until employment is obtained and/or job
searches have been fulfilled. During this period Participants are responsible for their child care costs.**
Definition of Education Program:
• Enrolled in an accredited college course with a minimum of 9 credits; which can include online courses.
• Enrollment in classes to obtain HS Diploma/HSED/GED with a minimum of ¾ time status
• Vocational Rehabilitation/Probation Terms: Until the program is completed. Must notify the Program
Manager immediately.
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• Drug or Alcohol Rehabilitation Programs: This can either be inpatient and/or outpatient. Must provide
proof of enrollment. The program MUST be completed and Program Manager is to be notified
immediately upon completion.
Documentation of class schedules and/or other supporting documentation of enrollment in the above
education programs is a requirement.
END OF EMPLOYMENT/END OF EDUCATIONAL PROGRAM/LOSS OF
CHILDCARE
If the parent(s)/guardian(s) employment/education ends, notification is to be given to CCAP within 5 business
days. Child Care Assistance can still be utilized for a maximum of (3) three consecutive months for job
search/absence from school. The job search/school break time frame is limited to a one time occurrence per
household within a 12 month period. At that time, employment or return to school must be established or
payments will not be authorized and your household will then be removed from the program. You are able to re-
apply when you have returned to school or employment is gained. During this time, co-payments will be
adjusted to reflect the new household income.
Participants who are unemployed, in the 477 or W2 programs, are required to complete and submit the Job
Search Form that is found in the appendix of the application.
A minimum of 8 job searches per month must be completed and the job search form must be submitted to the
CCAP Manager for continual participation in CCAP.
Parent/Guardian’s must give CCAP a two week notice before changing providers. If you are a current
participant on the program, you have 90 days to secure new childcare. If childcare is not secured before the 90
day period, your family will be removed from the program and placed on the waitlist. CCAP will not hold a
position on the program past the 90 day loss of childcare period.
HOURS OF SUBSIDIZED CARE ALLOWABLE WEEKLY
Maximum subsidized care cannot exceed 50 hours per week without prior approval from CCAP Manager. If not
approved and there are charges due to the overage of hours, the parent(s)/guardian(s) maintain sole
responsibility of payment for that difference.
ABSENCES POLICY
• Each family is allotted one week of “vacation” time that CCAP will pay subsidy for in a 12 month
period.
• Children must be in attendance a minimum of 85% of their scheduled time or parent(s)/guardian(s) have
the sole responsibility for payment of those absent days.
• Absences due to illnesses that are 3 consecutive days or more require a written doctor’s note submitted
to the Program Manager.
The only exception for absences from the child care center that are over a week long is cultural events, a
documented illness, maternity leave or an extenuating circumstances that is approved by the CCAP Manager.
The Child Care Assistance Program does not hold child care positions at any child care centers with the
exception of Maternity Leave.
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MATERNITY LEAVE POLICY
Maternity Leave can be given for up to 12 weeks for Parent(s)/Guardian(s) that are currently participating in the
program to take time off work to be with their newborn. This allows not only the Parent(s)/Guardian(s) and
siblings to bond but also to hold your position at the child care center until your return to work.
During the Maternity Leave period, CCAP allows for payment of the provider’s usual charges (or some portion
thereof, if a lower charge cannot be negotiated to hold that spot) during the 12 week period whether or not the
children attend.
Co-payments will be adjusted to reflect the difference in wages during this time.
If a parent/guardian chooses to not return to work after maternity leave, the parent will be removed from CCAP
permanently.
NEWBORNS FOR CURRENT PARTICIPANTS
If you are a current participant and become pregnant, your newborn is not guaranteed to be placed on the
program. If funds are not available and there is a current waitlist, your newborn only will be placed on the
waitlist in the appropriate order, but your children currently participating will remain on the program. *see
waitlist eligibility*
EILIGIBILITY REQUIREMENTS FOR CHILDREN
• Child must be an enrolled Ho-Chunk tribal member or in the process of enrollment. There is a one year
grace period for enrollment. If enrollment is not obtained or the child has not been named in the Ho-
Chunk Nation Worak prior to the year deadline, the child will no longer be eligible for CCAP assistance
until enrollment is complete. This means your child will be suspended from the program until enrollment
is completed. Suspension will only apply to your child that did not make the one year grace period for
enrollment, any other children remain and continue as participants.
• Child must be a resident of the custodial parent(s)/guardian(s) home of a minimum of 51% of the time.
This includes placement/foster care or temporary custody children.
• If assistance if requested by both parents sharing physical custody (50/50), a separate application is
required for each parent as they are considered to be separate households. If custody is not 50/50, the
parent over 50% custody will be eligible for participation. Court Documentation is required, unless
approved by the CCAP Manager.
• Child must be under the age of 13 unless they are considered “special needs” (documentation is required
to determine eligibility)
DEFINITION OF HOUSEHOLD
Below are the individuals that are required on the Child Care Assistance Program application.
• Parent(s)/Guardian(s)
• Dependent children under the age of 18 living in your home
• Unmarried domestic partner if you have a child together and/or guardianship
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• Married partners
*If a household member is currently incarcerated or becomes incarcerated during program participation, the
family is still eligible for participation within the program. Co-payments will be adjusted for income and
household size during this time*
COMBINING OF HOUSEHOLDS
Co-Habitation:
• If co-habitating and you have a child together, a new complete application will be required to combine
households and income from both parent(s).
• Co-habitating with no children together you are considered single and fill out the application as such.
Marriage:
• If you get married a new complete application will be required and income from both parent/guardian
and spouse is required. You are combining households, which means all eligible individuals are to be
entered on the application.
Combining of households does not guarantee children from your partner/spouse can and will be added
immediately. If there is a current waitlist those children will be added in the appropriate order.
DIVORCE/SEPARATION
If current participants divorce, it is required to show legal documentation to the Program Manager. Until legal
documentation has been given, the application will remain as is, as well as the Co-payment, etc.
In the event of separation, notice must be giving within 10 business working days. *See Discharge Policy*
DEFINITION OF INCOME
The Child Care Assistance Program defines “Total family income” as parent(s)/guardian(s) income stated
below (with the exception of Per Capita) where the child resides a minimum of 51% of the time or in a 50/50
shared custody household.
Income below must be submitted with your application:
• Working wages – If wages are based on tips and/or hours vary; an average will be calculated using a
minimum of the last three paystubs. Dependent on the work performed a 12 month period may be used
to calculate the average.
• Disability income
• Child Support
• Social Security Income (SSI)
Must provide proof of income to Program Manager.
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ASSETS
You are required to list all assets on the application. Regardless of income level, assets with a total value of 1
million or more you are ineligible for the Child Care Assistance Program.
What is an asset: An asset is a resource that holds monetary value and can be converted into cash.
Examples:
Cash
Checking and Savings Accounts
Real Estate
Stocks, Bonds, Certificate of Deposits
Automobiles, Boats, etc.
Electronics, Jewelry and Collectibles
CO-PAYMENT
The parent(s)/guardian(s) have the sole responsibility for a small portion of their weekly child care charges
called a “co-payment”.
• The co-payment is determined using the fee scale created by the program. The fee scale is based income
and how many children require child care assistance.
• Co-payments are to be paid weekly to the child care center as their portion/responsibility of the child
care charges. If the co-payments are outstanding or overdue, the parent(s)/guardian(s) are out of
compliance and will be suspended from the Child Care Assistance Program until those amounts are
brought current. We need to ensure that integrity is maintained with our providers.
• The current calculated Co-Payment amount is a set amount and is not pro-rated upon the child’s
attendance.
REPORTING CHANGES
Any changes in (but not limited to) income, assets, person’s living in the home, a change in job/education status
or child care needs must be reported within 5 business days.
After 10 business days you may be suspended and/or terminated from the Child Care Assistance Program.
FRAUD
The Child Care Assistance Program defines fraud as withholding pertinent information intentionally from the
Ho-Chunk Nation Child Care Assistance Program that could change/alter your eligibility, status, income,
household, etc. The Child Care Assistance Program follows the Ho-Chunk Nation’s Policies and Procedures in
the event of fraud in recovering any overpayments.
*This will result in permanent removal from the Ho-Chunk Nation Child Care Assistance Program*
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FEES COVERED UNDER THE PROGRAM
• Yearly Enrollment/Registration Fees for the Child Care Center – Child Care Center’s yearly
enrollment fees are allowable for payment once per 12 month period/per child. If a parent/guardian
decides to switch child care centers within a given year, the parent will be responsible for the new
enrollment fee at the new child care center.
• Holidays – Holidays designated by the center the child attends and/or the Ho-Chunk Nation (if a tribal
employee) are paid for by the program.
FEES NOT COVERED BY THE PROGRAM
• Co-Payments- are the sole responsibility of the parent/guardian.
• Absent days beyond the 85% monthly attendance minimum
*exception being approval from CCAP Manager*
• All other addition child care fees – which includes, but is limited to: Holding fees, late fees, pick
up/drop off fees, application fees, provider/center closed and co-payments in arrears. If a child is
consistently absent from child care and there is a pattern of absences that have been developed; the
Child Care Assistance Program Manager reserves the right to require supporting documentation on the
nature of the absences.
REQUIRED DOCUMENTS FOR A COMPLETE APPLICATION TO
DETERMINE ELIGIBILITY
Applications for Child Care Assistance are accepted throughout the year. The following documents are a
requirement to determine eligibility and be considered for assistance:
1. Child Care Assistance Application: Application is located in the Appendix
Family Size Excludes:
a. The non-custodial parent (if mother and father do not live in the same residence)
b. Unmarried partner without guardianship and/or like child
c. The Child’s other non-parental relatives living in the home
d. Parent/Guardian children living in the home over the age of 18
e. Any persons who may be staying in the applicant’s home under age 19 that is not included as
providing support.
2. Decision Letter from the State Child Care Assistance: Approval or Denial Letter from the state in
wish you reside. It needs to indicate that parent(s)/Guardian(s) have followed through with all eligibility
requirement for Child Care Assistance and the decision on that application. The exception are
parent(s)/guardian(s) who are in a Drug or Alcohol rehabilitation Program and have been approved
through CCAP. The entire letter must be submitted, not just the page stating you were approved or
denied. Parents/Guardians will be not eligible for participation until the entire letter has been submitted
to the CCAP Manager.
3. Child’s certificate of tribal enrollment (copy): Child must be an enrolled Ho-Chunk Nation tribal
member or eligible and in the process of enrollment.
4. Enrollment Eligibility Form If your child is not currently enrolled (must be notarized): If a child is not
enrolled, but is eligible for enrollment and/or in the process of enrollment there is a one year grace
CHILD CARE ASSISTANCE PROGRAM
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period from start date with the program. The Enrollment Eligibility Form is required upon submission
off application and must be notarized.
5. Application Completion Checklist: Located in Appendix Section of this manual.
6. Parent/Guardian Policy Handbook Receipt Acknowledgement Form: Located in Appendix Section
of this manual.
7. Discharge Policy Form: Located in Appendix Section of this manual.
8. Release of Information Form: Located in Appendix Section of this manual.
9. Proof of Income: The Child Care Assistance Program requires proof of income (per capita is not
included) from the income defined below.
Income includes:
o Working wages – If wages are based on tips and/or hours vary; an average will be calculated
using the last three paystubs. Dependent on employment an average may be completed using the
last 12 months of income.
o Disability income
o Child Support
o Social Security Income (SSI)
10. Proof of Education Training-if applicable: Proof of enrollment in an educational program which
contains hours and/or schedule of training.
11. Drug or Alcohol Rehabilitation Program: Proof of enrollment which contains hours and/or schedule
must be submitted. Program must be completed.
12. Class Schedule-if applicable: Show the number credits taken in each semester (minimum of 9)
13. Proof of Residence: Rent/Lease/Purchase agreement. CCAP will accept other documentation as proof
of residence if not available. These forms must be discussed and be approved prior to submission with
the Program Manager.
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DECISION OF ELIGIBILITY
The Child Care Assistance Program Manager is delegated the authority for reviewing the application to
determine the accuracy and completeness of submitted application materials to determine eligibility.
Families who have received assistance previously on the program and are seeking assistance again need to
have left in good standing for future assistance. In addition, families need to have met any outstanding
requirements from previous participation (enrollment, outstanding fee, etc.)and meet the current criteria for
eligibility.
Once it is determined that the applicant is eligible; a final review is conducted by the Community Supportive
Services Coordinator and/or Director. If both are absent to determine eligibility, the Executive Director of
Social Services is included in the decision making process.
The Child Care Assistance Program Manager has 30 days to determine eligibility. If all supporting
documentation and/or the application remains incomplete after the 30 day period, the applicant is
required to start the application process over.
WAITLIST ELIGIBILITY
Due to limited funds, a waitlist may be formed. Families that have submitted an application are placed on a
waitlist for assistance. The complete application must be submitted with all supporting documentation and
acknowledgement forms signed. Applying for state will not be necessary until you are being placed on the
program unless you are able to receive state benefits and/or directed by the CCAP Program Manager.
Placement/temporary guardianship, vulnerable children and special needs have priority on the waitlist. The waitlist is
compiled by child. For example if you are on the waitlist with your two children and one placement child, the placement
child will have priority, but your two children will maintain their position on the waitlist.
Participants that become pregnant are not guaranteed a position for their newborn child. If a current waitlist is formed,
that newborn will be placed on that waitlist, but your children currently participating will remain on the program.
APPROVED APPLICATION FOR ASSISTANCE
When a family is determined eligible for services; the Child Care Assistance Program Manager will notify the
applicant(s) in writing. This is done either through mail, telephone or via email. If there is no response within 10
business days, you will be moved to the bottom of the waitlist and we will contact the next family. If a family
has not completed the state application, this must be completed before participation in CCAP.
The following forms will be required after the application is been complete and has been approved for CCAP
participation:
• Family Acknowledgement Form: This form reiterates the responsibilities the parent/guardian has to
maintain assistance in CCAP.
• Co-Payment Agreement: The Agreement contains the amount that the parent/guardian has sole
responsibility to pay weekly to the child care center. In addition this form will also have the start and
end date of eligibility period.
Services/Assistance begins when the completed application is approved, not when the complete
application is submitted.
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Parent(s)/Guardian(s) and the Child Care Provider are required to sign this agreement and fill
it out in in its entirety.
• Program Compliance Form: This form is a validation that all the required documents for eligibility
has been submitted and received by the parent/guardian. This is also the justification form to the Ho-
Chunk Nation’s Treasury Department for payment to the Child Care Providers. Signature is required by
both the Program Manager and the Parent/Guardian acknowledging Program Compliance.
ELIGIBILITY AND REVIEW PROCESS
• Families currently participating in CCAP are required to go through the review process once per year to
update required information in order to maintain assistance. This is to ensure the program maintains
compliance for our program/grant guidelines.
• Notices are sent to families prior to their annual review date by mail or email with a date the annual
review is to be completed. It is a requirement to have all updated information completed and submitted
by that date or families will be suspended until completed and will have responsibility for full payment
of child care rates until reinstatement to the program. The Program Compliance Form is part of the
annual review process and if this form is not updated, payment will/cannot be authorized.
Adjustments to eligibility can be done at any time if the family’s circumstances have changed and
modifications need to be made to the family’s household, income, number of children requesting assistance,
etc. Parent(s)/Guardian(s) are required to notify CCAP within five business days of any changes in
household information. Documentation of those changes will be required to determine new eligibility status.
YOUNGSTAR
As a parent/guardian it can be challenging to find provider that is a good fit for your children. Youngstar gives
you the ability to search what centers are in your area (in Wisconsin), what they are currently rated at as well as
any violations if any there may be. The link is below for your review.
https://dcf.wisconsin.gov/youngstar
CHILD CARE ASSISTANCE PROGRAM
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APPEAL PROCESS
Department of Social Services utilized a “Complaint Reporting Form” for appealing a decision you are not in
agreement with. The Complaint Reporting Form must be submitted within 10 (ten) business days of date on
denial notification. The Compliant Reporting Form is to be submitted to:
Executive Director of Social Services
HCN Department of Social Services:
P.O. Box 40
Black River Falls, WI 54615
The complaint should state facts and should include:
1. Your identifying information – Name, address, phone and email address (if applicable).
2. The program you have a complaint with (check appropriate box on form).
3. Date of complaint/location of complaint/time/person involved.
4. Description of complaint – why you believe the decision is wrong. Specific information based on facts
and what the relief you are seeking.
All appeals will be addressed in a timely manner and will be followed up with a written response.
OFFICE LOCATION
808 Red Iron Road
Black River Falls, WI 54615
Phone: 715-284-2622
Fax: 715-284-9486
Office Hours: Monday – Friday 8:00 am – 4:30 pm
***The form is the last page of the appendix
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APPENDIX
APPLICATION COMPLETION CHECKLIST:
Application Completion Checklist
Decision Letter for State/County Child Care Assistance
Copy of Child’s certification of Ho-Chunk Tribal Enrollment
Parent/Guardian Policy Handbook Receipt Acknowledgement Form
Discharge Policy Form Must be notarized
Voucher Payment
Release of Information Form Must be notarized
Enrollment Eligibility Form (if child is not currently enrolled) Must be notarized
Proof of Income
Proof of Educational Program and/or Training – If applicable
Proof of Substance Or Alcohol Rehabilitation Program – If applicable
Proof of Residence
Class Schedule – If application
Job Search form – If Applicable
Completed Application
By Signing Below I understand in order for my application to be considered complete, all of the above items must be submitted to
CCAP to determine eligibility. Funds are first come, first serve so I may be placed on a waitlist in the appropriate order as defined
within the handbook.
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Revised 6/1/19
SECTION I: Applicant(s)
Parent/Guardian Name(s)-Living in the Home
Date of Birth
Tribal ID# (last 5
digits)
Parent/Guardian Name(s)/Spouse/Cohabitant
Date of Birth
Tribal ID# (last 5
digits)
Physical Address where you reside
Home Phone:
Cell Phone:
Work Phone:
Mailing Address (if different)
Email:
*Primary Communication is done electronically*
Parent(s) Absent from the home? Please list below:
Absent Physical Address:
Parent/Guardian Place of Employment and Job Site/School/Training
Organization and/or Program
Work Phone:
How many Hours per week are you employed or attending an education program?
Hours
Parent/Spouse/Cohabitant Place of Employment and Job
Site/School/Training Organization and/or Program
Work Phone:
How many Hours per week are you employed or attending an education program?
Hours
Parent/Guardian Household Asset Limitation:
I hereby affirm that my/our household assets do not exceed the one million maximum limitation.
Initials
SECTION II: List all children who reside in the home (Child must be under 13 years of age unless
disabled/verified special needs by a physician to receive child care assistance.)
Family Size EXCLUDES:
• The non-custodial parent (if mother and father do not live in the same household)
• Parent(s)/Guardian(s) partner if they do not have a child together or placement/temporary guardianship of a
child together
• The Child’s other non-parental relatives living in the household
• Parent(s)/Guardian(s) children living in the home over 18
• Any persons who may be staying in the applicant’s home under age 18 that the parent/guardian does not include
as providing support
Child’s Full Name
Date of
Birth
Child Care Needed?
(YES/NO)
Age
Gender
Tribal #
1.
YES
NO
2.
YES
NO
3.
YES
NO
4.
YES
NO
5.
YES
NO
6.
YES
NO
7.
YES
NO
8.
YES
NO
9.
YES
NO
10.
YES
NO
SECTION III:
Provider/Child Care Center your child(ren) currently attend or on waitlist to attend:
Center/Provider Name
Contact:
Phone:
Address
Email:
2
nd
Center/Provider Name (if applicable)
Contact:
Phone:
Address
Email:
• Please note that registration fees may be paid once in a twelve month period. If you choose to change child care
centers within the twelve month period, those registration fees are your sole responsibility.
• CCAP does not assist with application fees.
SECTION IV: Rights and Acknowledgements
1. I understand that all necessary documentation must be completed and submitted in before
the approval process can begin.
Initial
2. I understand that any changes within the household that could impact your eligibility
must be communicated in writing to CCAP within ten business days.
Initial
3. I understand that the Child Care Provider must be a state certified/state licensed or faith
based center following WI Early Learning Model Standard or the state of residence
equivalent.
Initial
4. I understand that I must apply for child care subsidy and receive a child care assistance
determination letter from the state in which I reside before my eligibility for CCAP is
determined. I understand I need to carry out all eligibility requirements when applying
through the state and submit the entire approval or denial letter to CCAP.
Initial
5. CCAP is not liable for claims, demands, obligations, losses, costs, damages, fines, or any
other type of liability, arising out of or resulting from any act, omission, willful
misconduct or gross negligence of the child care provider that is chosen by the
parent/guardian.
Initial
6. I understand that regardless of my household income, if my assets total 1 million dollars
or more I am not eligible for child care assistance.
Initial
7. I understand I am required to complete an annual review and could be subject to random
reviews.
Initial
8. I understand that I am required to give notice to CCAP of any absences within 24 hours.
Any absences that are more than three consecutive days may require a doctor’s note.
Initial
9. I understand policies can change without notice to maintain compliance and/or program
integrity.
Initial
10. AFFIDAVIT: I swear or affirm that all the information provided above is true and
understand that providing false information, deliberate misinformation or
intentional omission of information that results in obtaining benefits may result in
being removed from the Ho-Chunk Nation Child Care Assistance Program.
Initial
THE CHILD CARE ASSISTANCE PROGRAM IS SUBJECT TO CHANGE WITHOUT ADVANCED NOTICE.
I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CHILD CARE COSTS NOT PAID BY THE CCAP PROGRAM; INCLUDING
BENEFITS WHICH MAY HAVE BEEN AUTHORIZED, BUT FOR WHICH I NO LONGER QUALIFY BASED ON A CHANGE IN
CIRCUMSTANCES/ELIGIBILITY.
I HAVE READ ALL SECTIONS OF THIS FORM
APPLICANT
DATE:
APPLICANT
DATE:
Parent/Guardian Policy Handbook
Receipt
I have received and read the Parent/Guardian Child Care Assistance Program Policy Handbook.
1. I have read, understand and will adhere to the policies that are within this handbook.
2. I understand that policies can change at any given time to maintain integrity and/or compliance of the
Ho-Chunk Nation Child Care Assistance Program.
By signing below we acknowledge receipt and review of the Child Care Assistance Program’s Parent/Guardian
Policy Handbook.
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
CCAP Manager Signature
Date
DISCHARGE POLICY
THE HO-CHUNK NATION CHILD CARE ASSISTANCE PROGRAM (CCAP) RESERVES THE RIGTH TO
INITIATE IMMEDIATE/TEMPORARY/PERMANENT TERMINATIONS WHEN NECESSATY DUE TO ANY
VIOLATIONS OF POLICIES.
1. Parent(s)/Guardian(s) failure to pay overdue fees or co-payments to providers.
2. Parent(s)/Guardian(s) consistent inability to comply with the Child Care Assistance Program Policies.
3. Parent(s)/Guardian(s) failure to notify CCAP of any types of changes in writing that relate to CCAP within the
maximum of 10 business days.
4. Parent(s)/Guardian(s) submitting fraudulent information both verbally and/or written to CCAP.
5. Parent(s)/Guardian(s) falsification of signatures, hours and rates of services on any CCAP form.
REPORTING
1. Parents are obligated to immediately report any type of Neglect, Physical Abuse, Sexual Abuse, Mental Abuse and
Emotional Abuse to the proper authorities
2. Parents will give providers a two week/14 day notice when the parent has either become ineligible for
assistance or no longer wishes to utilize the child care center.
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Subscribed and sworn before me, I
, a Notary Public, in and for the (County)
and (state)
, do hereby declare the parties above did personally appear before me and
furnish to me adequate identification of providing their identity and stated they did in fact sign the document of
Their own free will, on this
day, of
,20
.
Notary Public Signature
Date
(Affix Seal)
• Parent(s)/Guardian(s) violating policy will be notified in writing and/or verbally of this action.
• Parent(s)/Guardian(s) will be given written notification if it is deemed necessary to terminate child care services.
• CCAP may proceed with an investigation if one is deemed necessary. You will be notified either written or verbally by the
10
th
work day regarding the investigation. A decision for continuance of child care services will be discussed at that time.
My signature acknowledges that I have read and fully understand the CCAP Discharge Policy.
VOUCHER POLICY
The submission of the Payment Voucher on a timely basis is the exclusive responsibility of both
the parent/guardian and provider. CCAP is not responsible for payment of vouchers past two
weeks of the last date of service, arrears and any late fees. Absent days are subject to approval
as per policy guidelines. All concerns must be in WRITING within 24 hours of any incident
in question not covered by the program.
Parents:
1. Review dates, hours and charges for accuracy.
2. Verify parent/guardian information is both completed and accurate.
3. Sign and date voucher WEEKLY to acknowledge all is true to your knowledge so the provider may
submit for payment.
I have read and fully understand the process of submitting the voucher payment forms. My signature on this
form states I am in agreement and will follow the guidelines.
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
RELEASE OF INFORMATION
Please review all sections of this form before signing below.
Your information cannot be passed on to any other agency/individual without your written/verbal permission.
RELEASE OF INFORMATION:
I,
hereby authorize the Ho-Chunk Nation Division of
Social Services (Child Care Assistance Program –CSS) to disclose and /or retrieve information and/or documentation pertaining to
my application, participation or eligibility either written and/or verbally to the following: Place of Employment, State Department
of Human Services, HCN Social Services, Child Care Center, children(s) school, HCN Enrollment; other specified here:_______
________________________________________________________________________________________________________
The purpose of this authorization is to enable the Ho-Chunk Nation Child Care Assistance Program to determine eligibility, verify
information and process my application for assistance. I understand that my records are protected under federal regulation
regarding Confidentiality of Records and cannot be disclosed without written consent unless otherwise provided for in the
regulations.
PHOTOGRAPHS: Children from time to time may be photographed, videotaped or audiotaped in the context of classroom
playground or off-site activities for child care only. This usage could include but not limited to pictures in the Nation’s website, tribal
newspaper, federal reporting, brochures, CCAP Facebook page and files. (if you prefer approval before using the photographs,
videos or audio, please specify below)
Initial
With prior approval
Child’s Full Name
Child’s Full Name
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
A copy of this release serves the same function as the original signed release. This authorization can be revoked at any given time by providing
written notification to the Ho-Chunk Nation Division of Community Supportive Services CCAP. I understand that any information released prior to
revocation of this authorization, cannot be retrieved. By signing below I have acknowledge I have read and understand the above information
.
Subscribed and sworn before me, I
, a Notary Public, in and for the (County)
and (state)
, do hereby declare the parties above did personally appear before me and
furnish to me adequate identification of providing their identity and stated they did in fact sign the document of
Their own free will, on this
day, of
,20
.
Notary Public Signature
(Affix Seal)
Date
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
ELIGIBILITY OF ENROLLMENT
FORM
I, (Parent/Guardian) affirm that (child) is eligible for
enrollment with the Ho-Chunk Nation. I understand that I have one years’ time from the start date of
participating in the Ho-Chunk Nation Child Care Assistance Program to have my child enrolled.
If it is found that my child is not eligible for enrollment, I understand that I have the sole responsibility to return
100% of the subsidy received during the enrollment grace period I have been allotted and pay back said funds to
CCAP.
If I do not get my child enrolled within the one year grace period given, I understand that I will be suspended
from CCAP until enrollment has been completed.
I UNDERSTAND BY SIGNING BELOW I AM AFFIRMING TO THE BEST OF MY KNOWLEDGE THAT MY
CHILD IS ENROLLABLE WITH THE HO-CHUNK NATION AND I HAVE THE SOLE RESPONSIBILITY TO
ENSURE ENROLLMENT IS COMPLETED IN THE ALLOTED ONE YEAR GRACE PERIOD.
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Subscribed and sworn before me, I
, a Notary Public, in and for the (County)
and (state)
, do hereby declare the parties above did personally appear before me and
furnish to me adequate identification of providing their identity and stated they did in fact sign the document of
Their own free will, on this
day, of
,20
.
Notary Public Signature
Date
(Affix Seal)
Clear
The above job searches can and/or will be contacted for verification.
I understand that failure to complete and submit the required job searches can result in suspension from the
program. Fraud as defined in the policy will result in permanent termination from CCAP.
Ho-Chunk Nation Child Care Assistance Program Job Search Form
Phone: 715-284-2622 Ext. 5148
Fax: 715-284-9486
Participant Name:
This form is to be completed and submitted to the Child Care Assistance Program Manager for Approval a minimum of once per
month (from the first date of job search status) during the 3 consecutive month job search period as stated in the policy. There is
a minimum of eight job searches per month required during this time.
Date
Name and
Address of Agency
Name of Contact
Person
(Printed)
Signature of Contact
Person
Phone Number
Results
Application
Completed
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Signature of Participant
Date
Resource Request Form
Please let us know if you would like any information on the following additional resources:
HCN=Ho-Chunk Nation
HCN-Life Skills
(budget counseling, job skills, healthy
coping skills, organizational skills, cultural activities, etc.)
VRNA-Vocational Rehabilitation for Native
Americans
HCN-Labor Department
HCN-Housing Authority
HCN-Department of Housing
HCN-Headstart
HCN-Tribal Aging Unit (TAU)
HCN-Language Division
Mckinney-Vento Act of 1987
Wisconsin Afterschool Network (WAN)
HCN-Veterans Affairs HCN-Economic Assistance Program
HCN-Youth Services
HCN-Food Distribution
HCN-Healthcare Center (715)284-9851
HCN-House of Wellness (608)355-1240
Workforce Development
Food and Nutrition Resources
Job Centers of Wisconsin: (Please Specify what
County)
HCN-477 Program
AODA (Alcohol and Other Drug Abuse Resources: (Please Specify what County)
TANF (Temporary Assistance for Needy Families)
HCN-Social Services Intake Line: 1-855-659-8820
HCN: AODA Contact Information
Black River Falls (715) 284-2622
Wittenberg (715) 253-3640
Tomah (608) 372-5202
Nekoosa (715) 886-5444
Baraboo (608) 355-1254
La Crosse (608) 784-3083
Other:
COMPLAINT REPORTING FORM
The purpose of this form is to assist you in filing a complaint
with the Ho-Chunk Nation Social Services Department.
STATE YOUR NAME AND ADDRESS:
Date Reporting:
Name:
Address:
Home Phone #:
Work
Phone #:
DIVISIONS
Please check which division you have a complaint with.
Youth Services (YS)
Community Support Service (CSS)
Domestic Violence (DV)
Child and Family Services (CFS)
Tribal Aging Unit (TAU)
Child Support Enforcement (CSE)
Date of Complaint:
Location of Complaint:
Time:
Person(s) involved:
DESCRIPTION OF COMPLAINT:
(Please describe your complain in detail below,
if you need more space to write, please use another sheet of paper
.)
Once the report is received by the department, we will investigate the complaint and respond within 10 (ten)
business days.
Docum
ents Attached
Please Mail the copies to:
Attn: Executive Director of Social Services HCN Dept.
of Social Services
PO Box 40
Black River Falls WI 54615
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PROGRAM Division of Ho-Chunk Nation Social Services (Ho-Chunk Nation)

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Completed 23 December 2020

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