Child Care Workforce Stabilization Grant Supplemental Application Form

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

Section 1: Grant Information (Form CCWS-B)

Name of Applicant(Required)

Hidden

Provider ID(Required)

Telephone Number(Required)

Email Address(Required)

Facility Name(Required)

Licensee Name(Required)

License Number(Required)

Facility Physical Address(Required)

County(Required)

Facility Mailing Address

Complete only if mailing address is different from physical address

Same as physical address

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

(Full-Time is defined as working more than 25 hours per week.)

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

(Part-Time Staff is defined as working 16-25 hours per week.)

Section 2: Child Care Workforce Stabilization Employee Roster (Form CCWS-E)

Month:(Required)

Year:(Required)

Employee Roster(Required)

Click the plus (+) icon to add additional employees.

First & Last Name of Staff

Role

FT or PT

Hire Date

Total Number of Employees(Required)

Section 3: Acknowledgement of Terms, Certifications, and Signature

By submitting this Application Amendment and/or accepting funds distributed pursuant to this Application Amendment, the undersigned certifies and agrees:

To be bound by any and all terms set forth in the original Application and to use any and all funds distributed pursuant to this Application in the manner set forth below;
The information included in this Application is true and correct;
The person whose signature is below is the applicant/owner/licensee or the authorized designee with the authority to sign the Application;
The person whose signature is below has reviewed and agrees to follow the grant guidance as it is written on today’s date.

Signature(Required)

Enter your full legal name as your signature.

Date(Required)

A copy of your completed application will be emailed to the email address provided above for your records. Please be sure to check your inbox and (if necessary) spam folder for this important email.

Name

This field is for validation purposes and should be left unchanged.