Scholarship Recipient Information

Child's Information (Scholarship Recipient)

Child's Name (First & Last)

Child's Date of Birth

Gender

Male

Female

Where does your child attend care?

Does your child have an IEP or IFSP?

Individualized Education Plan (IEP)

Individualized Family Services Plan (IFSP)

None

I don't know

Was your child born premature?

Yes

If you answered "yes" to the above question, type the number of weeks premature

Have you been referred to our program by the Department of Children and Families (DCF)?

Yes

How did you hear about Raising Riley?

Child Demographics

Child's Ethnicity

Hispanic / Latino / Spanish Origin

Non-Hispanic / Non-Latino / Not Spanish Origin

Does this child speak a language other than English at home?

Yes

Child's Primary Language

English

Spanish

Other

Other Qualifying Information

Are you a Migrant Worker?

Yes

I don't know

Are you experiencing a family emergency or have an individual need to be taken into consideration?

Yes

If you selected "yes" for the question above, please specify here:

Have you received Raising Riley Child Care assistance in the past?

Yes

If you selected "yes" for the question above, please provide the child's name and approximate dates of previous scholarship here:

Parent / Guardian Information (Primary Contact)

Primary Caregiver's Name (First & Last)

Primary Caregiver's Date of Birth

Relationship to Child

Mother

Father

Other

Street Address

Street Address 2

City

Zip Code

County

Phone

Primary Caregiver's Ethnicity

Hispanic / Latino / Spanish Origin

Non-Hispanic / Non-Latino / Not Spanish Origin

Primary Caregiver's Primary Language

English

Spanish

Other

Primary Caregiver's Health Insurance

Private Insurance

Tri-Care (Military Insurance)

No Insurance

Other

Household Information

Number of persons living in the household (include yourself and recipient)

Number of children that are under 18 living in the household (include recipient)

List all residents living at your address. This includes roommates, family members, etc.

Resident #1 Name (First & Last)

Resident #1 Date of Birth

Relationship to recipient

Resident #2 Name (First & Last)

Resident #2 Date of Birth

Relationship to recipient

Remaining Residents ONLY if applicable

Resident #3 Name (First & Last)

Resident #3 Date of Birth

Relationship to recipient

Resident #4 Name (First & Last)

Resident #4 Date of Birth

Relationship to recipient

Resident #5 Name (First & Last)

Resident #5 Date of Birth

Relationship to recipient

Resident #6 Name (First & Last)

Resident #6 Date of Birth

Relationship to recipient

Resident #8 Name (First & Last)

Resident #8 Date of Birth

Relationship to recipient

What is your current Housing Arrangement

Stable Housing

Temporary Housing

Homeless / Living in Shelter

Other

In the past year, has your family had to sleep in a temporary living arrangement?

Yes

Financial Information

Primary Caregiver's Employment Information

Name of Employer

Employer's Phone #

Pay Rate $ (hourly / salary)

Hours worked in a week

Secondary Employment Information (if applicable) (secondary caregiver or second job)

Name of Employer

Employer's Phone #

Pay Rate $ (hourly / salary)

Hours worked in a week

Please add any notes or additional employment information (if applicable)

Does your family RECEIVE any of the following:

Child Support (direct or indirect)

Yes

Amount received MONTHLY:

File upload

DCF Child Care Subsidy

Yes

Amount received MONTHLY:

File upload

Discount or other reduction in tuition from child care provider

Yes

Amount received MONTHLY:

File upload

Any other assistance with childcare

Yes

Amount received MONTHLY:

File upload

If you selected "yes" for the question above, please specify here:

REQUIRED: Please attach the following information (where applicable):

Three (3) MOST RECENT paystubs

File upload

Employment Verification Letter (if you do not have paystubs due to recently starting a job)

File upload

Documentation of Marital Status (legal separation agreement, divorce decree, etc.) - if applicable

File upload

International Students: Copy of lawful presence documentation and financial support letters from home government - if applicable

File upload

Enrollment Verification - if applicable

KSU Students can share the Student Self-Service Academic Certification form that can be found on your KSIS account.

Students attending another university / college can submit a copy of your enrollment.

File upload

Choose an option

Child's IEP / IFSP - if applicable

File upload

Expectations and Responsibilities

In submitting this application:

I declare that this application is true and correct.

I understand that if I receive a Childcare Scholarship to which I am not entitled as a result of providing false information, I must repay the cost of that assistance.

I understand that my child must be enrolled in full-time care (35+ hours / week) with a licensed childcare provider.

I understand that parents / guardians must be individually employed and working at least 30 hours a week. Parents / Guardians attending school can qualify if enrolled full-time in high school classes or enrolled in either 12+ hours for undergraduate studies or 9+ hours for a Master's program. A combination of employment and school can be considered if the hours equal full-time status.

I understand that this information may be shared between Raising Riley and my childcare provider to verify eligibility.

I understand that it is my responsibility to provide proof of income, student status, and other requested information needed to determine eligibility for this program and that failure to do so can result in my application / scholarship being denied.

If I receive a Child Care Scholarship:

I understand that my eligibility status or scholarship amount may change to reflect any additional childcare subsidies.

I understand that I must notify Raising Riley two (2) weeks prior to exiting the scholarship program for any reason. Failure to do so could jeopardize future awards.

I grant permission to the Raising Riley program to exchange information with other agencies offering family and child supports and services. (EX. ACCYN, DCF, Childcare provider, USD 383, Infant / Toddler Services, Riley County Maternal and Child Health, WIC).

I understand that award amounts are subject to change based upon the availability of funds.

I understand that it is the parent / guardian's responsibility to notify Raising Riley in writing within 5 days when a change in circumstances takes place, such as marital status, job changes, student status changes, income changes, additional childcare subsidies received (ACCYN, DCF, SBA, etc.), new household members, new childcare providers, etc. Failure to do so may result in loss of funding.

I agree to meet with a Raising Riley representative for orientation. Scholarship will begin when orientation is completed.

I agree to allow three (3) mandatory assessments to be completed by a Raising Riley representative as scheduled and participate in three (3) assessment follow-up discussions with the Raising Riley representative.

I agree to participate in other observations facilitated by the Raising Riley program that are part of grant guidelines.

I understand that if my child exits the program, developmental assessments must be completed by the Raising Riley program in order for final month's scholarship reimbursement to be dispersed. If not completed due to parent / guardian non-notification, then my child's scholarship will be suspended for the last month's attendance and parent / guardian will be responsible for payment in full to the childcare provider.

I understand that proof of income, student status, and other requested information needed may be requested annually or as often as the Raising Riley program deems necessary.

I understand that Raising Riley reserves the right to refuse services based on non-compliance with this participation agreement.

To Whom it May Concern:

I herby authorize any person, agency, or institution to supply information concerning myself or my family as requested by Riley County Health Department - Raising Riley and to allow inspection and reproduction of records in their possession by any duly authorized representative of Raising Riley and the Riley County Health Department. I herewith release any person, agency, or institution from any and all liability to myself or to my family for supplying such information. This authorization is given only in connection with its use by Raising Riley and the Riley County Health Department in its administration of Raising Riley programs and for no other purpose.

By selecting this, you are agreeing to the above statement.

Date of submission

Please be sure to have your childcare provider complete the Enrollment & Fee Verification Form. This can be accessed at www.raisingriley.com located under the "PROVIDER INFORMATION" tab and the section titled "Enrollment & Fee Verification Form".

Thank you for your interest in the Raising Riley Childcare Scholarship Program. Please allow up to three (3) business days for Raising Riley to process your application. If you have any questions about your application, please feel free to contact the Raising Riley office at (785) 776-4779 ext. 7663