Child Care Statement	*This is not an application for Child Care Assistance	Date:

To be completed by the child’s Parent or Caretaker
Parent/Caretaker Name:	Case Number:
Address:	Zip Code:
Phone Number:	Social Security Number (not required, see below):
Reason for Care:	Job	School	Other:	** In-home Vendor Number:

To be completed by Provider
Provider Name:	Site Provider OCFS#
Care Site Address:	Zip Code:
Mailing Address:	Zip Code:
Phone Number:	Fax Number:	Date of Birth:
Site Vendor Number*:	*If NO Vendor Number, request a Vendor Request Form from DHS Caseworker or DHS Examiner or by calling (585) 753-6663.
I am on Temporary Assistance, Medical Assistance or SNAP:	No	Yes	If yes, my Case # is:
I have been found guilty of welfare fraud:	No	Yes	If yes, what County?
Is money still owed related?	No	Yes
What type of care if being provided? Check one:
Day Care Center	Registered Family Day Care (ATTACH COPY OF CURRENT LICENSE)
School Age Program	Group Family Home (ATTACH COPY OF CURRENT LICENSE)
Legally Exempt Group	Informal Care
Are you accredited?	No	Yes – List accreditation number (NAFDC or NAEYC):
Informal Provider must complete the following: CHECK ONE BOX ONLY
1.	I provide care in the child’s home. I understand that I am entitled to receive minimum wage and may be entitled to other employee benefits. I understand that the person who hired me (the child’s parent/caretaker) is my employer and payments from DHS will be issued under the parent’s In-home vendor number.** The child’s parent or caretaker is responsible for the difference between minimum wage and the amount the Department of Human Services can pay for child care. Provider and Parent/Caretaker MUST also complete and submit the Agreement for Legally Exempt In-Home Child Care.
2.	I provide care in my own home and (check whichever box applies):
a.	grandparent,	great-grandparent,	great-great grandparent,	aunt/uncle,
great-aunt/uncle,	brother/sister, or	first cousin	of all children in care.
b.	I provide care for no more than two (2) children (not counting my own & not counting children who are 13 years of age or older).
c.	I provide care for three (3) or more children. However, I never have more than two (2) children in care at the same time for more than three (3) hours a day.
3.	I provide care other than choices #1 and #2 above.	Explain:
*Legally Exempt Group Providers must complete the following. Check whichever applies to your program:
This is a nursery school, pre-kindergarten or day care program for children three years of age or older or a program for school-age children conducted during non-school hours, operated by a public-school district which is providing elementary or secondary education or both in accordance with the compulsory education requirements of the NYS Education Law. The program is located on the same premises or campus where the elementary or secondary school is provided.
This is a nursery school, pre-kindergarten or day care program for children three years of age or older or a program for school-age children conducted during non-school hours, operated by a private school or academy which is providing elementary for secondary education or both in accordance with the compulsory education requirements of the NYS Education Law. The program is located on the same premises or campus where the elementary or secondary school is provided.
This program is a nursery school or program that is voluntarily registered with the NYS Education Department and operates in accordance with Part 125 of its regulations. Attach a copy of your registration.

This program is a nursery school or program for preschool-age children, operated by a non-profit agency or organization or a private proprietary agency which is not voluntarily registered with NYS Education Department and which provides services to children for three or less hours per day.
The program is a summer day camp operated in accordance with Subpart 7 -2 of the State Sanitary Code and holds a valid permit from the Department of Health. MUST HAVE A CURRENT DOH PERMIT TO OPERATE A SUMMER DAY CAMP.
This program is a family day care center, family day care home or other child care program located on federal or tribal property and operated in compliance with applicable federal or tribal laws and regulations.
None of the above statements describe this program. If this is your answer, you may need to be licensed. Until you are licensed or provide documentation that you are legally exempt from licensing, MCDHS cannot pay you to provide child care. For information about licensing, contact the Bureau of Early Childhood Services at 1-800-732-5207.

For the following questions, CHECK the answer which applies to you:
1.	I (allow) (do not allow) the parents or legal caretakers of the children listed on the front side of this form unlimited and on demand access to their children, to written records regarding their children, and to the premises and myself whenever their children are in care.
2.	I (have) (have not) received all fees from the parents or legal caretakers which are due me as of this date.

To be completed by Parent or Caretaker and Provider together:

List Start Date:
Who will be in care? List the names and dates of birth of all the children the provider is watching (other than provider’s own children). Attach an additional page if needed.

Child’s Name	Date of Birth	Relationship to Provider
Who should be contacted in an emergency?	Phone where parent/caretaker can be reached:
Name of emergency contact person:
Phone of emergency contact person:

When is care needed? For each child, write the EXACT hours that he/she is in your care; i.e. 6:00 a.m. – 7:30 a.m., 2:30 p.m. – 5:00 p.m.

How much does the provider charge? Indicate the rate the provider is charging for each child in care.

Child’s Name:	*Amount $	Per hours day week
Mon a.m. p.m.	Tue a.m. p.m.	Wed a.m. p.m.	Thurs a.m. p.m.	Fri a.m. p.m.	Sat a.m. p.m.	Sun a.m. p.m.
Drop off time
Pick up time

Child’s Name:	*Amount $	Per hours day week
Mon a.m. p.m.	Tue a.m. p.m.	Wed a.m. p.m.	Thurs a.m. p.m.	Fri a.m. p.m.	Sat a.m. p.m.	Sun a.m. p.m.
Drop off time
Pick up time

Child’s Name:	*Amount $	Per hours day week
Mon a.m. p.m.	Tue a.m. p.m.	Wed a.m. p.m.	Thurs a.m. p.m.	Fri a.m. p.m.	Sat a.m. p.m.	Sun a.m. p.m.
Drop off time
Pick up time

Child’s Name:	*Amount $	Per hours day week
Mon a.m. p.m.	Tue a.m. p.m.	Wed a.m. p.m.	Thurs a.m. p.m.	Fri a.m. p.m.	Sat a.m. p.m.	Sun a.m. p.m.
Drop off time
Pick up time

Child’s Name:	*Amount $	Per hours day week
Mon a.m. p.m.	Tue a.m. p.m.	Wed a.m. p.m.	Thurs a.m. p.m.	Fri a.m. p.m.	Sat a.m. p.m.	Sun a.m. p.m.
Drop off time
Pick up time

Child’s Name:	*Amount $	Per hours day week
Mon a.m. p.m.	Tue a.m. p.m.	Wed a.m. p.m.	Thurs a.m. p.m.	Fri a.m. p.m.	Sat a.m. p.m.	Sun a.m. p.m.
Drop off time
Pick up time

*NOTE: By signing this form, the provider attests that the amount charged for listed children does not EXCEED the amount charged for other children of the same age.

Who will provide meals and snacks? Check the box that fits your situation.

The provider	The parent/caretaker	Other

What else does the provider need to know? Use this space to describe anything special about the child that the provider needs to know. This might include infant feeding schedules, allergies, health problems, likes and dislikes, special needs or disabilities, etc.

I understand that representatives of the Department of Human Services and the State of New York may visit my child care program to confirm that the information on my enrollment form and/or attendance is true and accurate and that child care services are being provided as listed on those forms. I agree to allow representatives of the Department of Human Services and the State of New York access to all areas where child care is provided for a child receiving a child care subsidy. I understand that if I do not allow such access, then I will be considered an ineligible provider. The Department of Human Services will not make payments for any child care service I provide while I am deemed an ineligible provider by the Department of Human Services.

I understand that the provider is not an employee of the Monroe County Department of Human Services. I further understand that child care payments that he/she receives directly or indirectly for providing child care will not make him/her an employee of Monroe County.

I will notify the Department of Human Services immediately if the hours of care change, if any child is absent for three (3) consecutive days without explanation, or if a decision is made by either the parent/caretaker or provider to end child care. Except in an emergency, the parent/caretaker agrees to give the provider at least one-week notice if he/she will be stopping child care. The provider agrees to give the parent/caretaker one-week notice if he/she must stop providing care.

I agree to provide accurate attendance records as required by and in accordance with the instructions of the Department of Human Services.

Parent/Caretaker AND Provider must sign
I certify that to the best of our knowledge and belief all statements made on this form are accurate and true. I understand that providing false information may result in the termination of payments and legal action by the Department of Human Services.
X
Provider Signature	Date
X
Parent/Caretaker Signature	Date