Quality Counts Child Care Grant Application

Training Grant

July 1, 2012 – June 30, 2013

Funded by the Illinois Department of Human Services

èThe original application and budget forms must be used

èPlease type or print using black or blue ink

èComplete all blanks, use “NA” if not applicable

èAdditional documentation may not be added once the grant is submitted to the CCR&R

I. Contact Information

Program Name (if applicable):

Contact Person:

Program Location:

City: IL Zip: County:

Mailing Address (if different than program location)

City: IL Zip: County:

Daytime phone: / Email

Social Security or Federal ID Number (required):

II. Program Information

The program is (check all that apply): o For-profit o Not-for-Profit o License Exempt

o Family Child Care Home o Group Family Child Care oChild Care Center o Head Start o School Age Only o Licensed: IDCFS License #: __ Expiration: ______

Is the program listed on the CCR&R referral database? …………………………………………………. o Yes o No Requirement of grant

Did someone from the program attend an Information Session? ………………………….... . o Yes o No Requirement of grant

Which date: ______Name of attendee: ______

Is the program full time / full year (at least 8 hours per day and at least 47 weeks per year)? ..…… o Yes o No

If the program is school age only, does it operate a minimum of nine (9) months per year? .……… o Yes o No o Not Applicable

Is the program a Quality Counts Quality Rating System Program? …………………………………..o Yes o No

If yes circle: Star Level 1 2 3 4 or Training Tier I II III

Is the program accredited?……………………………………………………………………………………..o Yes o No

If yes, list Accreditation

Does the program receive Head Start Funding? …………………………………………….……………. o Yes o No

Does the program receive ISBE Preschool for All funding? …………………………………………….. o Yes o No

Has the program received a Quality Counts Grant between July 1, 2009 and June 30, 2012? …… o Yes o No

III. Capacity/Enrollment Information

Total Capacity Current Enrollment (based on the date of the application)

Child Care Center / Ages / Family/Group Child Care Home
Lic. Capacity
(If applicable) / Total # enrolled / Total # Enrolled
Infants (6 weeks – 14 months)
Toddlers (15 months – 23 months)
2 Year Olds (24 months – 36 months)
Preschool (36 months – 59 months
School Age (60 months – 12 years)

Licensed Programs – Capacity is the capacity listed on the program’s IDCFS license

License Exempt - Capacity is the total number of children that can be cared for at any one time

Family/Group Child Care – for enrollment totals include your own children under age 13

Enrollment Numbers – total can exceed the capacity due to part-time children and/or shift care

Is the program currently caring for children whose families receive IDHS Child Care Assistance Program (CCAP) funds?……..o Yes o No

If yes, complete the following:

IV. Please answer the following. Use only the space provided.

A. Explain why you are requesting to be part of this Training Grant and what you hope to accomplish. Also, if you participated in the Training Grant last year please explain why you would like to participate again.

B. Describe the program improvements you would like to see in your child care program in the next three years. ______

V. Authorization

I agree to complete all of the required training and activities of this program.

I certify that the above information is true and accurate, that I have not been indicated of child abuse or neglect and that my name or employees are not listed on the child abuse and neglect tracking system. Further, I grant permission for a representative of the Illinois Department of Children and Family Services or their agent to release information about a pending or current Day Care Home or Day Care Center license. I understand that a representative of the Illinois Department of Human Services or CCR&R staff may conduct an on-site visit to verify use of grant funds as awarded and approved.

Authorized signature and title Date

All sections of the application are complete and NA was entered in any blank that is not applicable

The application is signed and dated

A copy of your DCFS License has been included if applicable

A copy of your Quality Counts QRS certificate OR QRS Summary/Facility Report OR the letter that a QRS level was not achieved has been included if applicable

A total of two (2) sets of documents (the original + one (1) copy) are included

Quality Counts Child Care Grant Training Grant Application Page 1 of 2