Enrollment & Fee Verification Form

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Raising Riley

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Child Care Enrollment and Fee Verification Form

This form is to be completed by the director of the child care center or the child care provider and returned with the completed application.

Provider Information

Note: Providers must have permanent license and be in good standing with KDHE.

Do you accept DCF funds?

Yes

Do you check e-mail regularly?

Yes

Enrollment Information (via provider)

Is child enrolled in full-time care?

Yes

Tuition Charged

Monthly

Weekly

Child Care Center or Family Child Care Provider Responsibilities

This completed page must accompany each scholarship application

Be a licensed child care provider or center

RR has access to “real-time” licensing survey findings. Partners with the RR scholarship program are expected to meet high standards for the health and safety of children in care. These standards may or may not exceed licensing standards. If RR deems a facility’s operations reflect non-compliance, then a suspension from this partnership could result until the issue is resolved. Should there be repeated non-compliance concerns, Raising Riley scholarship participation may be terminated.

Located in Manhattan/Riley County

Provider must complete and submit Child Care Scholarship Request for Payment form monthly for payment. *A Welcome to Raising Riley visit will be made by RR Facilitator once scholarship is awarded. The facilitator will outline how to submit for your monthly reimbursement. Reimbursement will be paid directly to provider

Allow a Raising Riley facilitator to visit home /center classroom for an observation twice a year.

Notify Raising Riley of any change in family or employment status, additional tuition assistance, the number of hours a child is in care, or intent to exit this child.

I certify that the information listed above is accurate to the best of my knowledge and that this child is enrolled in care.

Provider Signature

Thanks for submitting!

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