PARENT AGREEMENT FOR CHILD CARE SERVICES

□ Initial Determination □ Re-determination □ Status Change □ Other

Parent
Name: / Address: / Telephone:

This form has been developed to help clients understand the enrollment agreement and their rights and responsibilities to receive child care assistance through the Workforce Solutions Heart of Texas Child Care Services. Before you sign this form, please read carefully to be sure that you have answered each question correctly.

PARENT RESPONSIBILITY AGREEMENT (not applicable to TDFPS and Career Center Referrals)

Initial

____I received an explanation regarding child support, substance abuse, and school attendance of my children. I understand that I

  • must help establish paternity for my child(ren) and help obtain child support for my child(ren).
  • must not use, sell or possess marijuana or a controlled substance, or abuse alcohol.
  • must make sure that each child in the household under the age of 18 attends school regularly, unless the child has a high school diploma or GED credential or is exempt from school attendance by Texas Education Code..
  • must provide documentation if currently in or have completed a drug rehabilitation program.
  • I understand that I must comply with the provisions of the agreement listed above and will be reviewed each time eligibility of child care services is redetermined.
  • I understand that failure of the parent or caretaker to comply with the provisions of the Parent Responsibility may result in denial of child care services.

PARENT ENROLLMENT AGREEMENT

Initial

____I understand the available child care services, my rights and responsibilities, and the process to receive and continue the child care services.

  • I must be working and/or in school at least 25 hours per week for a single parent household and 50 hours per week for a two-parent household.
  • I must notify CCS of any changes that affect my eligibility for services within 10calendar days after the change occurs.
  • I must report to CCS any change in my residence, telephone number, or child care arrangements.
  • I must provide all required documentation and sign all required paperwork.
  • I must return all required forms within 12 calendar days from the day CCS sent the request.
  • I must pay the parent fee to the child care provider in advance, before receiving the child care.

Initial

____I was allowed to choose my child care arrangement that my family is utilizing.

Initial

____I understand and will meet the requirements of the child care facility.

  • I will meet the enrollment requirements of the child care facility that I choose.
  • I will notify the provider when my child is going to be absent and tell the reason for the absence. I understand that my child’s care will end if my child is absent for more than 30 days in a 12 month period or 5 consecutive days of absences with no provider contact.

Workforce Solutions for the Heart of Texas - Child Care Services

1416 S. New Road, 2nd Floor ▪ Waco, Texas 76711 ▪ (254) 296-5374 ▪ FAX (254) 753-6355

The Heart of Texas Workforce Board, Inc. is an equal opportunity employer/programs and auxiliary aids and services are available upon request to include individuals with disabilities. TTY/TDD via RELAY Texas service at 711 or (TDD) 1-800-735-2989 / 1-800-735-2988 (voice).

  • I will provide information including health and immunization records, authorization to secure medical assistance, and parent contact information to be used in case of an emergency.
  • I will be on time and honor the child care facility’s starting and closing hours. I will pay any charges incurred if I am late picking up my child.
  • I will make sure someone is home with my child until the bus arrives each morning and someone is home when my child arrives home in the evening.
  • I will report to TDFPS licensing office any possible violation of licensing standards which affects the care of children in the facility.
  • If I need child care on any of the provider’s nine paid holidays, I will make and pay for my own arrangements.
  • I will make other child care arrangements when I am no longer eligible for child care services.

Initial

____ I release CCS, the HOTWORKFORCE Board, and TWC from any responsibility for the quality of the child care services my child may receive from the facility of my choosing.

Initial

____ I understand that a person may be prosecuted if the person obtains or attempts to obtain, by fraudulent means, services to which she/he is not entitled.

PARENT RIGHTS

Initial

____ I understand that I have the following rights:

  • To have someone represent me when applying for child care services.
  • To appeal denial, reduction, or termination of services.
  • To have complaints or grievances heard without the threat of loosing my child care.
  • To have my information used to determine eligibility treated as confidential.
  • To receive services without regard to race, sex, color, national origin, age, political beliefs, religion, or disability.
  • To be notified in writing at least 15 calendar days before the denial, reduction, or termination of child care services, except in Choices and CPS cases.
  • To visit the child care facilities before making my choice of a child care provider.

PARENT SHARE OF COST (Parent Fee) (not applicable to TDFPS and Choices Referrals)

Initial

____I agree to pay in advance the fee amount of ______weekly______monthly

directly to: ______, the child care facility where my child

receives care, effective ______/______/______.

Initial

____I agree to pay the partial fee amount of ______for the month of______.

Initial

____

  • I understand that fees must be paid in advance, before receiving the child care.
  • I understand that any child care subsidy I receive from another agency must also be paid to the child care facility where my child receives care.
  • I understand that the fee amount is based on my gross monthly income, the number of household members, and the number of children I have enrolled in care.
  • I understand that my share of the cost must be paid, even if my child is absent or is not there for the full month.
  • I understand that if I do not pay the amount specified on this form, child care services for my child will be discontinued.

CUSTOMER AWARENESS INFORMATION

(Staff must read this section to parent)

Initial

____ I UNDERSTAND that I must be working at least 25 hrs a week, or attending college at least 9 semester credit hrs per semester, or in a training activity in order to receive child care services. I Understand that I may receive services not to exceed four years in order to complete an associate’s degree listed on the HOTWDB Targeted Occupation or two years to complete a post high school technical training or certificate program.

Initial

____ I GIVE PERMISSION to the Texas Workforce Commission (TWC), Heart of Texas Workforce Development Board (HTWDB), The Child Care Services (CCS) contractor, (or agency under contract), to contact a third party to verify, income, family size, medical information, education and/or training.

Initial

____ I UNDERSTAND that I qualify for child care based on my family’s income, the number of household members. I will inform CCS within 10 calendar days about changes in my work, school, training activities, or family size. (For example, a raise, bonus, commission, or get married).

Initial

____ I UNDERSTAND that it may be considered stealing child care services if I continue to receive services and I do not notify you within 10 calendar days of any changes in my work, training, or education status; my income; benefits; family; or marital status. I understand that failure to report changes may result in termination of services; recovery of payments, and my case may be turned over to the appropriate county or district attorney’s office for possible criminal prosecution.

Initial

____ I CERTIFY that I will comply with all of the requirements, policies and procedures of the Texas workforce Commission (TWC), Heart of Texas Workforce Board, Child Care Services (CCS) Contractor, and the child care provider while my child is enrolled in CCS child care and that the information I have provided to CCS is true and accurate.

Initial

____ I AGREE to comply with the provisions of the Parent Responsibility, Parent Enrollment, Parent Rights, and Parent Share of Costs Sections that I initialed above and as is set forth in the Parent Handbook.

Initial

____ I ATTEST that the information stated above is true and accurate, and understand that the above information, if misrepresented or incomplete may be grounds for immediate termination and/or penalties specified by state law.

______

Signature-Applicant/Firma-SolicitanteDate/Fecha

______

Signature-Child Care RepresentativeDate/Fecha

OFFICE USE ONLY

Good Cause - Parent Responsibility Act (if applicable):

Workforce Solutions Heart of Texas

ORIENTATION TO COMPLAINT FORM

This Orientation to Complaint Form addresses complaint procedures for the listed programs and services administered in the local workforce development area by the Heart of Texas Workforce Development Board and its Contractors:
Workforce Investment Act (WIA)
Temporary Assistance for Needy Families (TANF) / CHOICES
SNAP E&T
Child Care Services (CCS)
Employment Services
Trade Adjustment and Trade Readjustment Allowances (TAA and TRA)
**Detailed instructions and the appropriate address for the program in which you are enrolled in is listed on the backside of this form.
(Las instrucciones detalladas y el direccionamiento apropiado se enumera en la parte posterior de esta forma.)

The recipient of the federal financial assistance is:

Heart of Workforce Development BoardEqual Opportunity (EO) Officer: Aquanetta Brobston

801 Washington AveTitle: HOTWB Quality Assurance/EO Officer/504 Coordinator

Suite 700Telephone Number: (254) 296-5385

Waco, TX 76701TDD/RELAY Texas: 1-800-735-2989

The Heart of Texas Workforce Development Board (the Board) shall resolve complaints in a fair and prompt manner. Acts of restraint, interference, coercion, discrimination, or reprisal towards complainants exercising their rights to file a complaint under this procedure are prohibited. This procedure applies to all customers, applicants, and participants who have cause to file a complaint related to activities or programs administered by the Board.

All attempts will be made to resolve complaints of a non discriminatory nature at the local Heart of Texas Workforce Center. If you have received rude treatment, feel that you were given incorrect information about the programs and/or services provided at any HOT Workforce Center, have allegations of non-compliance with employment services regulations, or have other employment service related allegations of violations of employment laws, please contact the on-site Workforce Center Manager. If you are not satisfied or cannot reach resolution and still wish to file a complaint concerning any of these programs, you may submit your written complaint to the Board’s EO Officer.

After your written complaint has been received, the EO Officer will notify you of the next step in the complaint procedure. As long as you wish to pursue your complaint, the Board or Contractor will follow the steps described in the Complaint Procedure. You should study the Complaint Procedure carefully, and if you feel that steps required by the Complaint Procedure are not being followed, contact the EO Officer. Remember that at any stage of the Complaint Procedure you feel that you are not being provided enough help, you should contact:

Texas Workforce Commission (TWC)Telephone Numbers:

Equal Opportunity Monitoring(512) 463-2400

101 E. 15th St., Room 242-TRelay Texas: 1-800-735-2989

Austin, TX 78778-0001TTY 1-800-735-2988 (Voice)

EQUAL OPPORTUNITY IS THE LAW

It is against the law for this of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of race, color, religion, sex, national origin, age, disability, political affiliation or belief; and against any beneficiary of programs financially assisted under Title I of the Workforce Investment Act of 1998 (WIA), on the basis of the beneficiary’s citizenship/status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA Title I-financially assisted program or activity. The recipient must not discriminate in any of the following areas: deciding who will be admitted, or have access, to any WIA Title I-financially assisted program or activity; providing opportunities in, or treating any person with regard to, such a program or activity; or making employment decisions in the administration of, or in connection with, such a program or activity.

What to do if you believe you have experienced discrimination. If you think that you have been subjected to discrimination under a WIA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with the recipient (Heart of Texas Equal Opportunity Officer), or with: The Director, Civil Rights Center (CRC), U.S. Dept. of Labor, 200 Constitution Avenue NW, Room N4123, Washington, D.C. 20210. If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center. If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your complaint with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.

IGUALDAD DE OPORTUNIDADES ES LA LEY

La Ley require igualdad de oportunidades: El destinatario de asistencia financiera del Gobierno Federal tiene prohibido por ley discriminar, con base en los conceptos a continuación: discriminar a cualquier persona en los Estados Unidos por motivos de su raza, color, religión, sexo, origen nacional, edad, incapacitación, filiación o ideología política; discriminar a cualquier beneficiario de programas que cuenten con apoyo financiero a tenor del Título I de la Ley de Inversión en la Fuerza Laboral (Workforce Investment Act o WIA) de 1998, por motivo de la ciudadanía o calidad migratoria del beneficiario en tanto inmigrante legalmente autorizado para trabajar en los Estado Unidos; o por motivo de su participación en cualquier programa o actividad que cuente con apoyo financiero a tenor del Título I de la WIA. El destinatario de tal asistencia no debe discriminar en ninguno de los conceptos a continuación: en decidir quiénes han de ser admitidos o tener acceso a cualquier programa o actividad que cuente con apoyo financiero a tenor del Título I de la WIA; en la provision de oportunidades en tal programa o actividad y en el trato a cualquier personal con respecto al programa o actividad; o en la toma de decisions de empleo en la administración de tal programa or actividad o con respecto a lo mismo.

Qué hacer si usted cree haber sido discriminado/a: Si cree haber surfido discriminación en un programa o actividad con apoyo financiado a tenor del Título I de la WIA, puede presentar una queja, dentro de los 180 días subsiguientes a la fecha de la supesta infracción, con el Oficial de Igualdad de Oportunidades del destinatario de aistencia federal (o la persona designada por el destinatario para ese efecto), o bien, con el: Director del Centro de Derechos Civiles (CRC), Civil Rights Center (CRC), Dept. Federal Del Trabajo (U.S. Dept. of Labor), 200 Constitution Avenue NW, Room N4123, Washington, D.C. 20210. Si presenta su queja con el destinatario de asistencia federal, tendrá que esperar a que éste le expida un Aviso de Acción Definitiva por escrito, o hasta transcurridos 90 días (en la más temprana de las dos fechas) antes de presentar su queja al Centro de Derechos Civiles). Si el destinatario de asistencia federal no le entrega un Aviso de Acción Definitiva por escrito dentro de los 90 días de la fecha de presentación de su queja, usted no tiene obligación de esperar a que el destinatario le expida dicho Avison para presentar una queja con el CRC. Por orta parte, la queja con el CRC debe presentarse dentro de los 30 días del vencimiento del plazo de 90 días, es decir, dentro de 120 días a partir de la fecha en que presentó su queja con el destinatario. Si éste le entrega un Aviso de Acción Definitiva por escrito con respecto a su queja y usted sigue inconforme con la decisión o resolución, puede presentar una queja con el CRC. Hay que presentarla dentro de lost 30 días subsuguientes a la fecha en que recibió ell Aviso de Acción Definitiva.

Please do not sign this notice until you have read it and understand its contents.

This is to certify that I have read the Orientation to Complaint Procedure and that I have been given the opportunity to ask questions about its contents. By my signature below, I acknowledge this orientation to the Complaint Procedure and the statement regarding Equal Opportunity Is The Law.

Favor de no firmar sin haber leído este aviso y comprende su contenido.

Por esta, confirmo que he leído el Orientación de Dar Quejas Para Aplicantes y Participantes, y que he tenido la oportunidad de hacer preguntas acerca de su contenido. Por mi firma abajo, declaro que he recibido esta orientación a la Póliza De Dar Quejas y que entiendo la sección titulada Igualdad De Oportunidades Es La Ley.

Applicant Signature (Firma) Print (Nombre (en letra de molde) Date(Fecha)

AN EQUAL OPPORTUNITY EMPLOYER / PROGRAMS

Auxiliary aids and services are available upon request to individuals with disabilities

PROGRAMA DE OPORTUNIDADES DE IGUALDAD DEL EMPLEO

Ayundantes auxiliaries y servicios estan disponibles para individuos con incapacidades a peticion

INSTRUCTIONS ON HOW TO FILE A DISCRIMINATION COMPLAINT

(INSTRUCCIONES DETAILADAS PARA CLASIFIAR UNA QUEJA)

 WORKFORCE INVESTMENT ACT (WIA):

If you think you have been subjected to discrimination under a WIA Title I-financially assisted program or activity, you may file a complaint within 180 days from the date of the alleged violation with either; the recipient’s Equal Opportunity Officer (or the person whom the recipient has designated for this purpose); or Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue NW, Room N-4123 Washington, DC 20210 If you file your complaint with the recipient, you must wait either until the recipient issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center (see address above). If the recipient does not give you a written Notice of Final Action within 90 days of the day on which you filed your compliant, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90-day deadline (in other words, within 120 days after the day on which you filed your compliant with the recipient). If the recipient does give you a written Notice of Final Action on your complaint, but if you are dissatisfied with the decision or resolution, you may file a complaint with CRC. You must file your CRC complaint within 30 days of the date on which you received the Notice of Final Action.