Americorps CARE CAREGIVER INFORMATION and REGISTRATION FORM
NACCRRA
1515 N. Courthouse Road, 11th Floor
Arlington, VA 22201
Phone: 1-571-527-3226
U. S. AIR FORCE EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP)
RESPITE CARE FOR ACTIVE DUTY AIRMEN
RESPITE CARE PROVIDER/PROGRAM INFORMATION AND REGISTRATION FORM
To complete this application online, go to: https://fap.americasteamforchildcare.org
or fax to 571-255-4881 or email to AFEFMPrespite@naccrra.org
Provider/Program Name:
(As it appears on license/registration)
Check Any That Apply:
A. ¨ Respite Care In-Home Provider
B. ¨ Family Child Care Provider
¨ CDA Credentialed FCC Provider ¨NAFCC Accredited Provider
¨ Licensed ¨ Regulated/Certified
C. ¨ Licensed Child Development Center
¨ Nationally Accredited Program, if applicable. Which accreditation? ¨NAEYC ¨NAC ¨ NECPA
D. ¨ Special Needs Center/Program
Provider/Program Mailing Address: ______
______
City State Zip Code
County in which care is provided: ______Contact Name: ______
Provider/Program telephone number: (______) ______-______
E-Mail Address: ______
Provider/Program Social Security or Taxpayer Identification Number (TIN): ______-______-______
DIRECT DEPOSIT ACCOUNT INFORMATION
A voided check MUST be attached for the account designated below.
Bank Name: ______City: ______State: ______
Checking Account Savings Account
Account Number: ______
Automated Clearing House (ACH) Number: ______
Signature: ______
NOTE: ALL PARTICIPATING PROVIDERS MUST SIGN UP FOR DIRECT DEPOSIT
PROVIDER/PROGRAM RATES/FEES
EFMP Respite Care Hourly Rate $______2nd Child EFMP Respite Care Hourly Rate $______
3rd Child EFMP Respite Care Hourly Rate $ ______Respite Care Sibling* Hourly Rate $______
*Typically developing sibling
Please check all boxes:
¨ The rates listed above are the true and correct rates that I charge all respite care parents.
¨ I understand that NACCRRA Military Programs cannot pay me more than I charge private pay clients.
¨ I understand that I must notify NACCRRA Military Programs at least 15 (fifteen) days prior to any rate change in order for the new rate to be honored.
¨ I understand that program or policy violations will result in having to repay money to NACCRRA Military Programs and/or suspension from future participation in the NACCRRA Military Programs.
¨ I understand that the program will only pay for the number of hours the family is eligible for and any additional hours provided will be paid in agreement with the parent.
Respite Care payments for multiple EFM children will be determined on a case-by-case basis by NACCRRA.
I have read all of the above, I understand its content, and I certify that the information I have provided is true and correct.
______/______/______
Signature (Provider/Program Owner or Authorized Agent of Owner) Date
PROVIDER/PROGRAM RESPONSIBILITIES AND CERTIFICATION
In addition to this form I have submitted:
(Fax, or email these documents to NACCRRA.)
o W-9 Form
o Child Care License
o National Accreditation certificate, CDA credential or Early Childhood Education or Child Development degree if applicable
I [the Provider/Program] understand/agree that (please check all boxes):
¨ Provider/program is subject to inspection by the partnering agency and/or NACCRRA.
¨ Provider/program will not transport children during respite care
¨ Provider/program will continue to meet all minimum requirements set by the USAF EFMP Respite Care (and state regulation, if required) and agrees to comply with all NACCRRA MILITARY PROGRAMS policies necessary for reimbursement.
¨ Provider/program will notify NACCRRA MILITARY PROGRAMS immediately when a child stops receiving care. I understand that any parent/guardian must be given access to his/her child(ren) at any time during care hours.
¨ Provider/program will submit electronically or mail the monthly attendance record NO LATER THAN the first (1st) day of the month following care or upon termination of care (if care stops before the end of the month). PLEASE NOTE: Reimbursement may be delayed if the attendance record is submitted electronically or is postmarked later than the 1st day of the month following care. In addition, reimbursement for 24-hour or overnight care may not be legal in all states.
¨ Provider/program will not charge a higher fee for children of Military Sponsors than for the same service to the public.
NOTE: Failure to adhere to this policy will result in provider/program being required to refund overpayments and in cancellation of this and future payments from NACCRRA MILITARY PROGRAMS.
¨ Provider/program agrees to repay NACCRRA MILITARY PROGRAMS any money received for which services were not provided.
¨ Provider/program agrees to notify NACCRRA MILITARY PROGRAMS at least fifteen (15) calendar days before ending child care services.
¨ Prior to reimbursement, the Provider/Program must first provide all information requested on the front of this form.
¨ The Service member must be determined to be and remain eligible to receive respite care services.
I have read all of the above and understand its content. I also understand that non-compliance with any of the above may result in termination of my participation in the NACCRRA MILITARY PROGRAMS.
______/______/______
Signature (Provider/Program Owner or Authorized Agent of Owner) Date
NACCRRA MILITARY PROGRAM RESPONSIBILITIES
þ NACCRRA MILITARY PROGRAMS is responsible for coordination of respite care payments and other related support services as necessary to the children and families served under this agreement.
þ NACCRRA MILITARY PROGRAMS will not pay more than one provider/program, for the same child (ren), for the same period of care.
USAF EFMP Respite Care Program Page 1 of 3
Program Location (city and state) ______
Version 3 (04/01/2012)