Dear Parent or Guardian:

Bristol Bay Native Association

Workforce Development Center

Child Care Program

P.O. Box 310 Dillingham, Alaska 99576

Phone 842-2262 or Toll Free 1-888-285-2262Fax 842-3498

Dear Parent or Guardian:

We are pleased that you are interested in applying for Child Care Assistance and hope we

are able to help. To get your application file in order and establish your eligibility, please

do the following:

1.

Fill out the attached application completely.

2.

Submit a completed Child Care Provider Registration Form (enclosed).

3.

Submit ALL copies or proof of income with your application. The previous year’s

taxes and W-2’s and last month’s pay stubs for current year and itemized fishing

statements.

4.

Submit proof that your children are Alaskan Native or Indian descendants (copy of

children's Tribal cards or copies of the children's birth certificates and copy of

parent’s

Tribal card)

5.

Everyone in the home over 18 years old needs to sign

PAGE 5

; an Authorization for

release of information form.

6.

Submit a copy of your all your child/ren's Immunization records.

1.

BBNA has 30 days to determent eligibility for your case.

2.

You are responsible for all of your child care expenses unless otherwise notified by

BBNA.

3.

We cannot determine eligibility, until we have all the required paperwork and

completed application forms.

4.

A completed child care application does not automatically mean a client is eligible

for

child care assistance.

5.

Child Care is approved from the date we receive ALL the necessary documents to

determine your case. No child care is approved before that date.

Child Care Assistance

The Child Care Development Fund serves individuals and families by increasing the availability, affordability, and quality of child care in the BBNA service area.

APPLICATION:

Client must apply for services using the Child Care Assistance Application Form. Client must choose their child care provider.

A. The child care provider can be a relative, friend, licensed daycare home.

B. If the client chooses a family daycare home (home that is not licensed, but can be a relative or friend) they must register with BBNA using the Child Care Provider Registration Form. The provider must be 18 or older and cannot reside in the home with the children or the client

C. A licensed daycare home must provide a copy of their license for the file.

D. If there is someone living in the home 18 or older, is not working, in training or in school, and is capable of caring for the children then child care cannot assist.

ELIGIBILITY:

A client’s eligibility is based on the following criteria:

A. Parent(s) must be involved in one of the following activities: working, training/education or subsistence activities.

B. Children must be Native Descendents. (Proof can be CDIB’s, Copy of parents’CIDB’s with copy of children’s birth certificates.)

C. Parent(s) past 12 months income must not exceed income guidelines. INCOME:

Eligibility is determined by using the client’s previous 12 month income OR projecting the client’s current income.

A. Past Net Income will be used. B. Projected net Income will be used.

Please note the rate of pay BBNA will remit to the child care provider. BBNA will provide notification of the maximum number of approved hours for payment per day, anything over this is the payment responsibility of the parent.

AGE Less than 8 hours Daily Rate

age 0-1 yr.

$5.00/hour

$40.00/day

age 13 mo.-3 yr.

$4.50/hour

$36.00/day

age 4 yr-12 yr.

$4.00/hour

$32.00/day

If you have any questions or need additional information please call our toll-free

number at 1-888-285-2262.

Today’s

Bristol Bay Native Association Workforce Development

Mailing Address: P.O. Box 310 Dillingham, AK 99576 Phone: (907) 842-2262 Toll Free: (888) 285-2262 Fax: (907) 842-3498

Applicant’s Central Intake and Short Employability Development Plan

Name: __________________________________________________ ________________________________________ Current Age ____________ (First) (Middle) (Last) (Also Known As - or Maiden name)

Social Security Number: __________-_______-__________ Date of Birth: _______/_______/___________ Gender:  Male  Female

Present Mailing Address: ____________________________________________ _______________________ ________ _______________ ( P.O. Box) (City) (State) (Zip Code)

Present Physical Address: ____________________________________________ _______________________ ________ ______________ (Street Address) (City) (State) (Zip Code)

Home Phone: (_____)______-________ Work / Cell Phone: (_____)______-________ Email Address: ____________________________

Tribally enrolled at (please circle or indicate “other”);

Aleknagik, Chignik Bay, Chignik Lagoon, Chignik Lake, Clarks Point, Dillingham, Egegik, Ekuk, Ekwok, Igiugig, Iliamna, Ivanof Bay, Kanatak, King Salmon, Kokhanok, Koliganek, Levelock, Manokotak, Naknek, New Stuyahok, Newhalen, Nondalton, Pedro Bay, Perryville, Pilot Point, Port Heiden, Portage Creek, South Naknek, Togiak, Twin Hills, Ugashik or Other ________________ Marital Status:  Single  Single and living with significant other  Married Separated  Divorce Widowed Family Status:  Single Individual  One Parent Family Two Parent Family Number dependents under 18 _______ Veteran?  No  Yes - Date of Discharge: _____/_____/_______ Registered with Selective Service?  Yes  No

Educational Status: High School Diploma - Year Graduated: ____ GED-Year obtained ____ OR Highest Grade Completed: ____ College/Vocational Graduate - Type of Degree: AA/AAS BA/BS MA/MS Other:___________________ Year _________

Some BBNA WFD programs and/or jobs are subject to drug testing. Are you willing to take a drug test?  Yes  No

Applicant Ethnicity Applicant Primary Goal (check one) Applicant Secondary Goal (check one) (check one)  Alaskan Native  American Indian  Asian  African American  Hispanic or Latino  Native Hawaiian  Pacific Islander  Caucasian  Other: _________________

 Enter postsecondary Education or Job Training

 Obtain or Improve a Job  Retain Current Job  Educational Gain

 Earn a H.S. Diploma, GED or college degree

 Subsistence Activities (carving, beading, sewing, etc.)  Obtain Child Care Assistance  Obtain Alaska Driver’s License  Other:

________________________________ I expect to meet this goal by:

_______/_______/__________

 Obtain or Improve a Job  Retain Current Job  Leave Public Assistance  Educational Gain

 Earn a GED or Secondary School Diploma  Enter Postsecondary Education or Job Training  Obtain United States Citizenship Skills  Increase involvement in child’s education  Increase involvement in child’s literacy  Increase involvement in community activities

 Subsistence Activities (carving, beading, sewing, etc.)  Other: __________________________________________ I expect to meet this goal by: _____/_____/_________

Page 2 Central intake Applicant Name:

_____________________________________________

Page 3 Central intake Applicant Name:

_____________________________________________

Bristol Bay Native Association Workforce Development

Mailing Address: P.O. Box 310 Dillingham, AK 99576~

Phone: (907) 842-2262 ~ Toll Free: (888) 285-2262 ~ Fax: (907) 842-3498

Applicant Primary Status Applicant Secondary Status Institutional Programs

(Check All That Apply)  Disabled

 Employed

 Worked 90 days or more this calendar year  Unemployed  Collecting

unemployment  Not in the Labor Force  On Public Assistance

(food stamps, general assistance, ATAP)  Living in a Rural Area

Last hourly wage: $______________ Unemployed since: ____/____/______

(currently on or received in last six months)

(Check All That Apply -optional)  Low Income  Homemaker  Pregnant  Single Parent  Teen Parent  Dislocated Worker  Learning Disabled Adult  Homeless  No Transportation  None of the above

(Check All That Apply)  In Correctional Facilities

Release date_________________  Offender on Probation until________  Felony  Misdemeanor

 On Third Party Custody

Release Date __________________  In Specialized Treatment: (Substance Abuse, Behavioral Health, API etc.) release date_____________________  None of the above

I certify that the information given on this application is true to the best of my knowledge. By signing my name, I agree to allow information from this form to be used for statistical and follow-up purposes. I understand that my name will never be used in any report and that all data will be kept strictly confidential. I have read, understand and been given a copy of my rights and responsibilities  Yes  No

Signature: Signature Date: __________________________ Guardian’s Signature: ____________________________________ Signature Date: __________________________

Additional Skills of Applicant: check all that apply

Computer Skills Commercial Driver’s License Plumbing

Fax Machine Hazwoper Certification Electrical

Copy Machine Asbestos Certification Laborer

Multi Line Phone Carpentry Fishing/Deckhand

10 Key Calculator Mechanic Child Care Provider

Word Processing Excel Other:

Household Members (Please list all household members)

Last Name First Name MI Relationship Tribal Member of Date of Birth Social Security #

Bristol Bay Native Association Workforce Development

Phone: (907) 842-2262 ~ Toll Free: (888) 285-2262 ~ Fax: (907) 842-3498

Types of Income

WA Wages TT Tribal TANF FC Foster Care Payments

SEA Seasonal Work/Fishing WC Worker’s Compensation BIA BIA General Assistance

SE Self Employment BP Bingo/Pull Tab Winnings SL Student Loans/Grants

DI Dividends UI Unemployment IN Interest

SSI Supplemental Security Income TI Tips and Gratuity CS Child Support & Alimony

SSA Social Security RI Rental Income APA Adult Public Assistance

PFD Permanent Fund Dividend FLS Family Support (Explain) PE Pension (other than

VB Veterans Benefits GR General Relief Veteran’s Benefits) CO Cash out Retirement/Pension OT Other (Explain)

Household Income (Please list all household members income)

Household member name

Type of Income

Gross Income Form of Proof

Last Day of Work

Weekly/Monthly?

Applicant Employer Name: _______________________________ Phone # _________________ Do you own home or rent? _______ Landlord Name: ___________________ Phone # __________ I hereby certify that all information listed above is true and correct. I understand that submitting misleading or falsifying information to gain benefits are grounds to denial of services and may lead to prosecution, fines and imprisonment

Signed: ______________________________________ Date: ______________________

FOR OFFICE USE ONLY Date Received:__________ Date Entered: ___________ Initials: _______Consumer #: _____

Request for Child Care

My chosen Provider is

___________________________________________

Applicant’s Signature Witness Signature (if “X”) Date

EMERGENCY CONTACT

Phone #

Care will be provided: ______in provider’s home _______ in a Center ______ in my home

(In parent’s home -MUST INCLUED: PARENT UNDERSTANDING FOR IN-HOME CHILD CARE FORM and IN-HOME PROVIDER CAREGIVER VERIFICATION – see CCDF Program Manager for details)

Bristol Bay Native Association

I am requesting hours of child care per day, days a week for the following children in

my household, who are under age 13:

1)__________________

______3) _

______5)

_____

2)__________________

______4)

______6)________________

_____

I am in need of child care assistance because:

I currently work hours per day, days a week.

Place of Employment Phone # .

I am attending training from / / to / / .

I am enrolled in school at .

I or my spouse engages in subsistence activities f/t p/t to help

Support my family.

My spouse works hours a day days per week

Place of Employment Phone # .

______ I have TANF requirements

Workforce Development Center P.O. Box 310

Dillingham, AK 99576

Toll free: 1-888-285-2265 or Local: 907-842-2262 Fax: 907-842-3498

Authorization for Release of Information

For Child Care assistance; everyone in the home over the age of 18 must sign.

Attach another sheet if needed.

I hereby authorize the release of all information needed by BBNA Workforce Development Center contained in the City Councils, Village Councils, State, and Federal, Private or Educational Agencies’ records to the organization listed above:

This authority shall continue in effect until this client is no longer of BBNA’s Workforce Development Center’s Services.

Furthermore, that authorization is being given to the BBNA Workforce Development Center to proceed on my behalf to provide employment assistance services included (but not limited to):

1. Referral to potential employers

2. Inclusion in a Talent Bank/Skills Survey

This information is needed for verification of eligibility for:

CLIENT Household member- over age 18 Household member- over age 18 ___________________________ __________________________ ____________________________ CLIENT Print full name Print full name Print full

___________________________ ___________________________ ___________________________ CLIENT Social Security Number Social Security Number Social Security Number ___________________________ ___________________________ ___________________________ CLIENT Date of Birth Date of Birth Date of Birth

___________________________ ___________________________ ___________________________

CLIENT Signature Signature Signature

____________________________ ____________________________ ___________________________

Bristol Bay Native Association Workforce Development Center

P.O. Box 310 Dillingham, AK 99576

Toll free: 1-888-285-2265 or Local: 907-842-2262 Fax: 907-842-3498

Photo Release of Authorization Form

I hereby consent, without further consideration or compensation, to the use (full or in part) of all photographs, digital photos or any video taping made of me during WFD/Training events and/or activities, by BBNA or the employer I will be working with. For the purposes of internet web productions to the web site

www.bbna.com or any monthly reports, newsletter, annual reports. Further, I release BBNA or any employment and/or training agency and their members from any liability which may arise from the use of those materials.

I DO NOT want photos of myself or my family published to the district website or any of the following listed above.

This Release will remain in full force and effect until withdrawn in writing by me. Name:

Community: Position: Signature: Date:

NOTIFICATION TO CLIENT

The Federal law concerning fraud states… “Whoever in any matter within the jurisdiction of any department or

agency of the United States, knowingly and willingly falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false fictitious or fraudulent statements or representations or makes or uses any false writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry shall be fined not more than $10,000.00 or imprisoned not more than five years or both.”

Under the Privacy Act. 5 U.S.C. 552 (a) (1) (2), Workforce Development cannot give out information you give the caseworker except Workforce Development can share this information with other Federal, State, Tribal offices and programs who have some responsibility with the Workforce Development Center for which you are applying. The information can also be given to those agencies when you ask them for a job or for some other benefit and for law enforcement purposes. This can be done without your written consent. For any other person or program wanting information is in your case record and you can ask to see it. If you believe some information is inaccurate, ask your caseworker about how to change the information in the case record.

This must be read and signed

Printed Name of Client

**IMPORTANT NOTICE ABOUT YOUR RIGHTS**

FAIR HEARING

Any person whose application is denied or not acted upon within 30 days, or whose benefits are reduced or terminated, has a right to a hearing before the Bristol Bay Native Association.

If you desire a hearing, you may request it by telephone, in person, or in writing through the Child Care Development Block Grant Program, P.O. Box 310 Dillingham, Alaska 99576. You must make your request within thirty (30) days after you receive notice of a decision on your Child Care Assistance case.

B.B.N.A. is available to assist you if you request a hearing. At the hearing you may represent yourself. You may also be represented by legal counsel (e.g. – Alaska Legal Services Corporation or by another person of you choice (e.g. –friend or relative.))

CIVIL RIGHTS

The Civil Rights Act of 1974 states “No person in the United States, on the ground of race, color, or national origin, shall be excluded from participation or be denied the benefits of federal assistance.” If you feel you have been discriminated against, you may file a complaint with the Bristol Bay Native Association or with the United States Department of Health and Human Services.

PARENTAL CHOICES

If your application is approved, you will have complete and total authority to select the type of child care you prefer and any specific child care provider, as long as the child care provider you identify meets the registration and/or State or Tribal licensing criteria, and is willing to enter into agreement with the Bristol Bay Native Association Child Care Development Block Grant Program to serve as a vendor. (Copies of the child care provider registration and the tribal licensing forms for the program can be obtained by contacting the C.C. and D.B.C. Coordinator at B.B.N.A. Social Services Department.)

AGREEMENT

If your household receives assistance, you must agree to the statement below. Any member of you household who deliberately breaks any rules and receives benefits to which they are not entitled to will be required to pay back the benefits received under false information and may be prosecuted.

I certify that I have checked the information on the application carefully and it is true and complete of the facts according to the best of my knowledge and belief.

I understand that it is against the law to make false statements and that I am subject to prosecution if I do.

I understand that a B.B.N.A. representative may call my home, and may contact other people in order to verify my eligibility for assistance. I also understand that information I give may be verified by computer cross-matching with other agencies.

I authorize the Alaska Department of Labor to release to the Bristol Bay Native Association, information about my eligibility for unemployment insurance and work credits.

I authorize the Bristol Bay Native Association to communicate with my child care provider and other agencies on my behalf, as it relates to the Child Care Development Block Grant Program.

I understand that my household can submit only one application for Child Care Assistance per year. Furthermore, I certify that this is the only application submitted from or on behalf of my household.

/ /

Bristol Bay Native Association

Workforce Development Center

Child Care Program

P.O. Box 310 Dillingham, Alaska 99576

Phone 842-2262 or Toll Free 1-888-285-2262Fax 842-3498

Dear Provider:

We are pleased that you are interested in applying to be an approved Child Care

Provider and hope we are able to help. To get your application file in order and

establish your eligibility, please do the following:

1.

Fill out the attached Child Care Provider Registration Form completely.

2.

Submit Interested Persons Report (Criminal Background Check) for all

members of the household whom are 16 years of age and older. This can be obtained

through the State Troopers office, or request an Ingens Online background check from

the BBNA CCDF Case Manager. * If you are providing care in the child’s home you

only need to submit a report for yourself. Additional approval is needed for care in

child’s home.

3.

Submit current TB test Results.

4.

Submit a copy of your Social Security Card along with the attached W-9 Form

5.

Submit a copy of your business license application and payment prior to

mailing off to the State of Alaska.

1.

BBNA has

30 days

to determent eligibility for your case.

2.

Child Care is approved from the date we receive ALL the necessary documents

to

determine your approval. Payments will not be paid before approval date.

3.

The provider must be 18 or older and cannot reside in the home with the

children or the client.

Please note the rate of pay BBNA will remit to the child care provider. BBNA will provide notification of the maximum number of approved hours for payment per day, anything over this is the payment responsibility of the parent.

AGE Less than 8 hours Daily Rate

age 0-1 yr.

$5.00/hour

$40.00/day

age 13 mo.-3

yr.

$4.50/hour

$36.00/day

If you have any questions or need additional information please call our toll-free number at 1-888-285-2262.

CHILD CARE PROVIDER APPLICATION Bristol Bay Native Association

Workforce Development Center P.O. Box 310

Dillingham, Alaska 99576 (907) 842-2262 Fax 907842-3498

Date_______________________________________

Each person who provides child care for a parent or guardian receiving child care assistance from the Bristol Bay Native Association’s Child Care Development Fund must complete a home visit at least once a year.

THE BRISTOL BAY NATIVE ASSOCIATION RESERVES THE RIGHT TO DENY REGISTRATION AND PAYMENT TO ANY PERSON OR AGENCY WHO IS DETERMINED BY THE TRIBE TO BE A

POTENTIAL DANGER TO CHILDREN BECAUSE OF CURRENT OR PAST ASSOCIATION WITH OR PARTICIPATION IN CRIMINAL ACTIVITIES, ALCOHOL OR OTHER SUBSTANCE ABUSE,

COMMUNICABLE HEALTH PROBLEMS, OR UNSAFE CHILD CARE PRACTICES.

THE REQUIREMENTS FOR ALL CHILD CARE PROVIDERS ARE ON PAGE 2 QUESTIONS 1-4

*If the child care provider cares for more than six children, unrelated to him/her, it is necessary that the provider be licensed by the State of Alaska Child Care Program. In this case, the provider must contact the State of Alaska Child Care Program at 1 888-268-4632 for licensure. You can find information, forms and applications on their web site at http://dhss.alaska.gov/dpa/Pages/ccare/default.aspx . BBNA requires that care givers are in

compliance with all State and Tribal licensing before authorization of payment.

INFORMATION ABOUT THE CHILD CARE PROVIDER

____________________________________________ _________________ _________________________

Name of Provider Date of Birth Social Security or other ID #

___________________________________________________ ___________________ __________________ Mailing address City & Zip Home Phone # Cell Phone #

__________________________________________________________________________________________ Physical location where care takes place – if in parent’s home - PARENT UNDERSTANDING FOR IN-HOME CHILD CARE FORM and IN-HOME PROVIDER CAREGIVER VERIFICATION MUST BE INCLUED

Education (circle the highest)- (some HS) (HS/GED grad) ( CDA )(EC Cert) (AA) (BA )(MS) Degree

major_________

List additional education or training ____________________________________________________________ __________________________________________________________________________________________

I allow BBNA to provide my contact information to parents/guardians seeking child care ____YES ____NO

OTHER HOUSEHOLD MEMBERS NAMES DATE OF BIRTH RELATIONSHIP TO PROVIDER SS OR ID # 1. 2. 3. 4. 5. 6. 7. What are your hours of care? _________________________________________________________________

What days will you provide care? ______________________________________________________________ Holidays off? ______________________________________________________________________________ What age range will you provide care for?________________________________________________________ Will you be available for ___________ drop-ins _____________ after school care

Where is care provided? ______in my home _______ in a Center ______ in Client’s home- (MUST INCLUED PARENT UNDERSTANDING FOR IN-HOME CHILD CARE FORM)

There may be times when you are ill or need help in an emergency; two back up providers are recommended.

Both providers must meet the health and safety requirements listed above (#2. & #3)

Primary backup care provider _____________________________________ Contact # ___________________ Secondary backup care provider ___________________________________ Contact # ___________________

CHILD CARE HEALTH / SAFETY CHECKLIST

PROVIDER YES NO

1 Are you 18 years of age or older?

2 Has everyone in the home; 16 years or older; obtained a Criminal Background Check? 3 Do you fully understand that you are required by law to report suspected child abuse? 4 Do you provide a smoke, drug and alcohol-free environment for the children in your care:

this includes the child care site and vehicle used to transport children?

5 Does each floor of the facility have at least one properly installed and maintained smoke and

THE FOLLOWING IS REQUIRED: Hav

e

Need

1.Business Licenses Expiration date:

2.Criminal Background Checks on all members of the household over the age of

16

3.TB results Expiration date: 4.Copy of Social Security card

carbon monoxide detector?

6 Is there a fire extinguisher, which is readily accessible and maintained in operable condition? 7 Are you current on your EC First Aide / CPR certification? Expiration date:

(submit copy for file)

8 Is there a first aid kit that is in a convenient location and is inaccessible to children? 9 Is there a list of emergency contact numbers – including the parent/guardians? 10 Is there an emergency evacuation plan?

11 Are there at least two ways of exiting the child care area?

12 Are poisons, toxic materials, cleaning substances, sharp or pointed objects, and guns kept in a safe place or locked up so children cannot get to them?

13 Are all outlets covered or non-accessible to children? 14 Are all small items checked against choking hazards?

15 Is there a safe play area provided, including inside and outside areas?

16 Are the floors and walls clean and maintained in a condition safe for children? 17 Ventilation, temperature, and lighting are adequate for children’s safety and comfort 18 Are toys and objects (i.e. high chair/ crib/ etc.) safe, durable, easy to clean and non-toxic? 19 Do you have home owners or rental insurance?

20 Has your water quality been tested? 21 Do you have a wood stove?

22 If so do you have a plan to keep children from potential harm?

CHILD’S HEALTH YES NO

23 Is all medicine, prescribed and/or over-the-counter; administered only with written parental instruction?

24 Do you use separate towel/washcloth on each child?

25 Do you diaper, change and toilet children away from the food preparation area? 26 Are parents notified of any accident or injury to the child?

How do you insure that allergies to foods/ environment are noted and observed? _________________________ __________________________________________________________________________________________ What form of discipline do you use? ____________________________________________________________ __________________________________________________________________________________________ How do you keep track of the mobile children? ___________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Do you have pets? ______YES _____NO

Are all pets current on rabies vaccinations? _____ YES _____ NO Have any of these pets harmed anyone either intentionally or by accident? _____ YES _____ NO

Explain ___________________________________________________________________________________ __________________________________________________________________________________________

How do you keep the children / pets safe from harm? ______________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

List all the children you will be providing care for Date of Birth Provider relationship 1. 2. 3. 4. 5. 6. _________________________ ____________________ _____________________ ____________________

Name of Parent #1 (client) Parent’s home # Parent’s Cell # Parent’s work #

_________________________ ____________________ _____________________ ____________________

Name of Parent #2 Parent’s home # Parent’s Cell # Parent’s work #

_________________________________________________________________________________________________ Parents address City/Village State Zip code

I certify that I will comply with all the requirements set forth by the Bristol Bay Native Association Child Care

Development Fund Program governing the registration of child care providers and that my answers to all the questions and statements I have made on the pages of this registration are true and correct to the best of my knowledge.

As a Child Care Provider, I agree to comply with the recommendations listed above. All recommendations will be followed through within 3 weeks from the date of this form. I understand that if the above recommendations are not completed within 3 weeks that my Child Care payments will be suspended until I have complied with the above requests. I allow BBNA to provide a copy of pages 1-3 of this Home Visit to clients whom are parents of the children I care for.

Signature: Child Care Provider___________________________________________ Date________________

>Signature: Parent of Child/ren ____________________________________________ Date ________________

>Printed: Parent of Child/ren __________________________________________________________________

Printed BBNA Representative _________________________________________________________________

Qualifi

cations of Persons Having Regular Contact with Children in a Child Care Facility

As per 4 AAC 62.210(b) and (d) as referenced in 4 ACC 65.185(a)(3): Approved Providers

An individual may not work, volunteer, or reside in a child care facility or in any other part of the premises housing a child care facility, if the individual has the opportunity to access to the child care facility and:

 Is the alleged perpetrator of an incident of child abuse or neglect in which the department of Health and Social Services found the evidence available substantiates the allegation, or the information available to the department demonstrates to the department the individual’s inability to adequately provide care and supervision to children:

 Has a physical, health, mental health or behavioral problem to an extent that the problem poses a significant risk to the health, safety, or well-being of children in care:

 Has a domestic violence or alcohol or other substance abuse problem to an extent that the problem poses a significant risk to the health, safety or well-being of children in care:

 Was the subject of prior adverse licensing action:

 Subject to the Barrier Crimes requirements as listed by the Barrier Crimes Matrix listed in 7 AAC 10.900-7 AAC 10.990 at the web site: http://dhss.alaska.gov/ocs/Documents/BarrierCrimeMatrix.pdf

 Was, at any time, under indictment, charged by information or complaint, or convicted of any of the following offenses:

* An offense against the family and vulnerable adults * Perjury under AS 11.56.200

* A serious offense

For a list of Barrier Crime offenses please request a copy from the Child Care Coordinator.

I have read and understand the above statement.

Bristol Bay Native Association

Child Care Provider Reference

This is a reference for which I have known for in the capacity of

Child Care Provider’s Name Year, Months

(Friend, Co-worker, Employer, etc.) Not an immediate Relative

I know this person: Very Well Casually Not well enough to give a reference

Please answer the following questions:

1. Does this provider show any serious health, alcohol or drug problems? Yes NO

If yes, please explain:

2. Can you attest to the good character, maturity and sound judgment of this provider? YesNo

If no please explain:

3. How would you assess the Providers ability to provide good care to children?

Check one: Excellent Good Fair Poor

4. List those qualities, which you believe will enable the provider to work successfully (or unsuccessfully)

5. If you needed a Child Care Provider, how would you feel about leaving your children with this Provider?

Very enthusiastic somewhat enthusiastic Worried Would NOT

Comments:

Address of Reference City State Zip Code

Bristol Bay Native Association

Child Care Provider Reference

This is a reference for which I have known for in the capacity of

Child Care Provider’s Name Year, Months

(Friend, Co-worker, Employer, etc.) Not a Relative

I know this person: Very Well Casually Not well enough to give a reference

Please answer the following questions:

1. Does this provider show any serious health, alcohol or drug problems? Yes NO

If yes, please explain:

2. Can you attest to the good character, maturity and sound judgment of this provider? YesNo

If no please explain:

5. How would you assess the Providers ability to provide good care to children?

Check one: Excellent Good Fair Poor

6. List those qualities, which you believe will enable the provider to work successfully (or unsuccessfully)

5. If you needed a Child Care Provider, how would you feel about leaving your children with this Provider?

Very enthusiastic somewhat enthusiastic Worried Would NOT

Comments:

Address of Reference City State Zip Code

Notification to Child Care Provider

The Federal law concerning fraud state… “Whoever, in any matter within the jurisdiction of any department or

agency of the United Stated, knowingly and willingly falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false fictitious or fraudulent statements or representations or makes or uses any false writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry shall be fined not more than $10,000.00 or imprisoned not more than five years or both.”

Under the Privacy Act 5 U.S.C. 552 (a) (1) (2), Workforce Development cannot give out the information you give the caseworker except Workforce Development can share this information with other Federal, State, Tribal offices and programs who have some responsibility with the Workforce Development for which you are applying. The information can also be given to those agencies when you ask them for a job or for some other benefit and for law enforcement purposes. This can be done without your written consent. For any other person or program wanting information is in your case record and you can change the information in the case record.

This must be read and signed

Child Care Provider’s Signature

Printed Name of Child Care Provider