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2. Contact Name*
3. Email Address*
5. Phone Number*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Organization Legal Name*
13. DBA or Alternative Name
15. Amount Requested*
16. Federal Employer ID Number (FEIN)*
18. Outline of organizational priorities/mission and values, equity commitment, childcare philosophy, history, board membership, etc.*
20. List of staff including any formal and continuing education and licensing.*
22. Description of type of childcare services offered*

    Be sure to include: Total number of seats available, Seats currently filled, Number of classrooms, License capacity per room, Staffing ratio, Program year - Calendar or Academic, If you are licensed to serve infants and/or toddlers, Website, if any

24. Select Grant Application Type*

    1. Sliding Scale Scholarships (complete section A.)
    2. Infrastructure Investment (complete section B)
    3. Staffing Support, Inclusive Special Needs Programming and/or Behavioral Support (complete section C)
26. List any other funding sources that have been considered or received. (Such as Preschool Promise, Head Start, SNAP, foundations/donors, local employers, etc.)*
30. If you are applying for Sliding Scale Scholarships, fill out section A, below
32. A. Proposed draft sliding scale used to identify/verify the level of need and priority in awarding affordability scholarships.
34. A. Outline of required information from the household used to evaluate their potential scholarship.
36. If you are applying for Infrastructure Investment, fill out section B, below

    For projects between $0 and $24,999, include two quotes. For projects between $25,000 and more, provide three quotes. If three quotes are not received, make a note of which agencies did not respond to the request for quote.

38. B. Project description, including the need you are addressing and how this investment will solve the need.
40. If you are applying for Staffing Support, fill out Section C, below
42. C. Please describe the type of staffing resources supported by this grant request.
44. C. How many full-time equivalents (FTE’s) will the grant request support, and for what duration (ex. 6-months, 1 year)?
46. C. What qualifications are required to meet the staffing resource objectives?
48. C. How does the addition of the staff member enable greater program capacity, expand program offerings, or add program support?
52. Upload the the following documents:
54. Documentation of state certification/licensure of applicant/childcare facilities*
55. Proof of Insurance*
57. Documentation of organization’s financial viability (990 tax form, recent income tax filings, liability insurance coverage, etc.)*
58. Proof of site control – for example deed, property tax statement, lease agreement or long-term rental agreement*
60. Provider rate/pricing structure
61. Documentation of non-profit status, if applicable
63. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
65. Electronic Signature*
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67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

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