Child Care Workforce Stabilization Grant
Application Form

Section 1: Grant Information (Form CCWS-A)

Please read all instructions on the Child Care Workforce Stabilization (CCWS) Grant page.

A copy of the facility’s W-9 is required for processing of this application. Additionally, if you elect to receive your grant via direct deposit, you must complete and return a copy of the ACH form. Both of these forms are available for download on the CCWS Grant page.

Name of Applicant

Telephone Number

Email Address

Facility Name

Licensee Name

Licensee Number

Facility Physical Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Facility Mailing Address

Complete only if mailing address is different from physical address

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Is the Applicant Hispanic or Latino?

Yes

No

Gender of Applicant

Male

Female

Number of Full-Time Staff Positions on the Facility's Payroll to Receive Bonus

Number of Part-Time Staff Positions on the Facility's Payroll to Receive Bonus

The provider is licensed, regulated, or registered, and meets Child Care and Development Fund health and safety requirements on the date of the application.

Yes

No

Is the child care facility currently in good standing with the Department (not on adverse action, including probation, revocation, or suspension?)

Yes

No

Does the child care facility serve children who are private-pay?

Yes

No

Does the child care facility serve children who are participating on the Child Care Subsidy Program?

Yes

No

Does the child care facility serve children enrolled in the DHR Early Head Start-Child Care Partnership Program?

Yes

No

Does the program exclusively serve children funded by State funded Pre-K, Head-Start, or non-DHR Early Head Start-Child Care Program? (If YES, the program must hold a DHR issued license to qualify.)

Yes

No

Is your child care facility currently open and operating for in-person services at the time you are submitting this application (not including temporary closures consistent with the ordinary course of business)?

Yes

No

Do you commit to remain open and operating for a period of one (1) year from the date of receiving the grant award (not including temporary closures consistent with the ordinary course of business)?

Yes

No

Choose payment method:

Check (CK)

Direct Deposit (DD) (To receive DD you must obtain and complete a DD form from your regional agency)

Remember to download, complete, and return the ACH Form to TCR to receive Direct Deposits.

Child Care Workforce Stabilization Grant Application Form

Section 1: Grant Information (Form CCWS-A)

Facility Physical Address

Child Care Workforce Stabilization Grant
Application Form