ASSISTANCE APPLYING FOR: (Check All That Apply)

SPOKANE TRIBAL TANF/477 CHILD CARE PROGRAM P.O. Box 358 Wellpinit, WA 99040 PHONE: (509) 458-8000 FAX: (509) 458-8017

Welcome to the Spokane Tribe of Indians TANF/477 Child Care Program. I would like to inform you that the child care program is able to offer parents/guardians the choice of all of the following types of child care categories: Center-based child care; Group-home child care; Family child care; and in-home care. In order to process your application for child care services the following information and identification is required:

1. Completed Application: Information pertaining to Parent(s) and Child(ren) (see attached)

2. Tribal Enrollment Verification in a Federally Recognized Tribe (Required) There needs to be one enrolled member in household in order to qualify for child care services. Provide a copy of one of the following as proof: Tribal Enrollment Card or CIB (Certified Indian Blood)

3. WCCC Approval, Denial, Or Waitlist Letter (If required; please ask our office for details) Can be addressed to either parent.

4. Applicant and Co-applicants Identification (Parent(s): Provide a copy of one of the following: Birth Certificate, Drivers License or State Picture I.D.

5. Proof of Residence (must include your name, address, and all household members) Landlord Statement, Lease agreement, Electric or Phone Bill

6. Income Verification: Applicant, Co-applicant and Child(ren) in Household: This includes employment, (F/T, P/T, OJT, WEX or OTHER) unemployment benefits, child support, survivor benefits, social security, State or Tribal TANF, alimony, (any type of income paid to the Applicant, Co-applicant and/or child(ren).

7. Child Identification: Birth Certificate, Tribal Identification, or Immunization record for each child in need of child care services. All of these documents have the required date of birth verification that we are in need of.

8. Proof of registration in: College, GED or High School, trade school or TANF/477 sponsored apprenticeship or training programs.

9. Custody Order: If you are a Foster Parent/Relative/Guardian given custody of the minor child(ren) documentation is required as proof. This includes parents who have been given temporary custody.

You can expedite the application process by providing complete information and documentation. If you are presently a TANF recipient I will need all the above information and a referral from your caseworker or CDS worker. The child care program is here to help decrease the number of families for which child care is a barrier to employment, College/Training, Trade School or while seeking employment.

If you have any further questions, please call (509) 458-8000.

1 SPOKANE TRIBAL TANF/477 CHILD CARE PROGRAM

( ) Single Parent Household ( ) Two-Parent Household ( ) Relative Placement ( ) Foster Care

ASSISTANCE APPLYING FOR: Full-time Childcare (above 5 hpd) Part-time Childcare DATE Temporary Child Care Other:______I/we are requesting child care while attending: Work College School/GED Classes TANF Workshop Employment Workshop Other: ______

APPLICANTS NAME (LAST, FIRST, MI) DATE OF BIRTH SOCIAL SECURITY # (optional)

CO-APPLICANTS NAME (LAST, FIRST, MI) DATE OF BIRTH SOCIAL SECURITY # (optional)

MAILING ADDRESS (P.O. BOX, CITY, STATE, ZIP)

PHYSICAL ADDRESS (If different, then mailing address):

HOME PHONE CELL # MESSAGE CONTACT NAME & #

Identify (1) Member in HH with Tribal Affiliation NAME OF TRIBE: ENROLL. #: (Parent or Child): PLEASE, LIST ONLY CHILD(REN) YOU ARE REQUESTING CHILD CARE FOR: 1). Childs Name: ______DOB: ______Age:______Type of Child Care: Child Care Facility Relative Care Licensed Family Home In Child’s Home Name of provider/facility:______Phone: ______Address:______Specify, whether child care needed: Full-time (5+ hours a day) or Part-time (Under 5 hours a day)

2). Childs Name: ______DOB: ______Age:______Type of Child Care: Child Care Facility Relative Care Licensed Family Home In Child’s Home Name of provider/facility:______Phone: ______Address:______Specify, whether child care needed: Full-time (5+ hours a day) or Part-time (Under 5 hours a day)

5). Childs Name: ______DOB: ______Age:______Type of Child Care: Child Care Facility Relative Care Licensed Family Home In Child’s Home Name of provider/facility:______Phone: ______Address:______Specify, whether child care needed: Full-time (5+ hours a day) or Part-time (Under 5 hours a day) PLEASE BE SPECIFIC: If there is an absent parent to one or more of the child(ren) you are requesting child 2 care for please list the parent(s) name and the child’s name.

Name: ______Address/Ph:______Childs Name: ______Does this parent have joint custody or visitation with the child? ( ) Yes ( ) No If yes, please be more specific: ______

TANF INFORMATION: Have you been a recipient of TANF, if so please complete the following information: Tribal TANF, if so where?______WHEN:______State TANF, if so where? ______WHEN:______A CHECK STUB OR LETTER FROM YOUR EMPLOYER IS REQUIRED (Only complete if employed) **ADoes check TANF stub plan or to letterprovide from a child your care employer referral: is required YES to NO determine DATE: eligibility**______CO-APPLICANT: Name of Caseworker EMPLOYERS: ______NAME HOURS: PHONE √ which #: one______applies 40 hours a week (F/T) 20 or less a week (P/T) Please, specify whether your case has been: CLOSED effective date:______EMPLOYER ADDRESS PHONE # Receive Support Services Only Over-income/Closed Voluntarily Terminated Over 60-months STARTCOLLEGE DATE INFORMATION:END DATE RATE OF PAY MAY WE CONTACT? APPLICANT: Are you attending START/END DATE: FIELD OF STUDY: FACILITY YES(Name &NO Address) (Your)College? JOB TITLEYES NO SUPERVISOR NAME SUPERVISOR TITLE CO-APPLICANT: Are you attending START/END DATE: FIELD OF STUDY: FACILITY(Name & Address) DUTIES: College? YES NO REASONEMPLOYMENT FOR LEAVING INFORMATION: APPLICANT & CO-APPLICANT (Only complete if employed) **A check stub or letter from your employer is required to determine eligibility** CHECKAPPLICANT: √ THE EMPLOYERS DAYS YOU ARE NAME SCHEDULED TO WORK: M HOURS: T W √ which Th. oneFri. applies Sat. Sun. 40 hours a week (F/T) 20 or less a week (P/T) LISTEMPLOYER ALL HOUSEHOLD ADDRESS MEMBERS & INCOME INFORMATION:PHONE #

HOUSEHOLDSTART DATE INCOME: BeginEND DATE by listing yourselfRATE and thenOF PAY anyone else youMAY provide WE financialCONTACT? support for or receive support from, usually consisting of your spouse and your child(ren). YES NO (Your) JOB TITLE SUPERVISOR NAME SUPERVISOR TITLE PLEASE, CHECK √ ALL THAT APPLY: DUTIES: Single-Parent Family Two-Parent Family Foster-Care Placement Relative Placement Non-Custodial Parent (Must provide Legal documents) REASON FOR LEAVING:

LISTCHECK ALL √ MEMBERS THE DAYS INYOU YOUR ARE HOUSEHOLD SCHEDULED BELOW: TO WORK: (Including M T children W Th.and those Fri. with Sat. no Sun.income) NAME: INCOME TYPE MONTHLY AMOUNT OF INCOME ______3 TOTAL HOUSEHOLD INCOME $______Income needs to be specified, especially if a child is receiving survivor’s benefits, social security, TANF, or foster care. ______Date:______Signature of Applicant

______Date:______Signature of Co-Applicant

Spokane Tribal TANF/477 CHILD CARE PROGRAM Landlord/Manager Statement

LANDLORD STATEMENT

PROPERTY OWNER OR AUTHORIZED MANAGER MUST COMPLETE THE FOLLOWING:

The Spokane Tribe TANF/477 Child Care Program is in the process of determining eligibility. Please provide the information requested below. Complete all sections below; please don’t leave any box blank.

Physical Address: ______Apt:______City: ______State: ______Zip:______Date Moved In: ______Date of Lease Expiration: ______List All Occupants (according to lease): ______Name of Person Paying Rent: ______Current Rent Amount: $______

Property Owner or Authorized Manager’s Name:______Address:______State:______Zip Code:______Daytime Telephone Number: ______Evening Telephone Number:______Property Owner or Authorized Manager’s Signature: ______Date: ______

I certify all information that I have given is true and correct to the best of my knowledge. I hereby authorize my Property Owner or Authorized Manager to provide the following information regarding my rental or lease agreement to the Spokane Tribal 477 Employment & Training program.

Print Name: ______Signature ______Date ______

4 Uniform Grievance & Appeals Procedure

The Spokane Tribe of Indians Employment and Training Department has established a uniform grievance and appeals procedure applicable to all participants within the program engaged in any type of activity included under the Public Law 102-477 Plan, and Employment and Training Department. The procedure insures due process and establishes a series of levels of review. All complaints are reviewed based on program procedures and official documentation.

Step 1: Informal/Verbal complaint – resolve informally with the staff member.

Step 2: Written complaint if Step 1 is unsuccessful. The written complaint will be received, date stamped, and delivered to the Assistant Director. The Assistant Director will investigate and respond to the complaint within ten (10) working days from receipt of complaint.

Step 3: Appeal Committee if the participant feels the complaint is not resolved; the written complaint must be forwarded to the Director. The Director will convene an Appeal Committee to review and respond to the complaint within ten (10) working days. The Committee will notify the participant of their decision within that ten (10) day period. All decisions made by the Appeal Committee are final.

The Appeal Committee will be comprised of the Director, a program manager, and a program specialist.

DRUG FREE WORKPLACE / NO FIREARMS ALLOWED

The Spokane Tribe of Indians Employment and Training Department maintains a safe and secure drug free workplace and does not allow illegal substances, drug paraphernalia, or fire arms upon its property. This policy applies to employees and guests. Anyone found in violation of this policy and/or breaking the law will be subject to appropriate actions including removal from the building or grounds, termination or suspension of services, and appropriate legal procedures. CONFIDENTIALITY

Any information I provide or that is obtained or received on my behalf is considered confidential. I understand all Employment & Training staff is required to maintain confidentiality of participants unless otherwise noted in the release of information to which I agree. RELEASE OF INFORMATION

I certify that the information given in this application is correct and true to the best of my knowledge and subject to verification. Falsification of facts is grounds for immediate termination from the program and may result in prosecution under law. I also herby authorize Employment & Training staff to obtain or release information included in this application as it pertains to my eligibility for services, and/or assistance sought on my behalf from other social services programs, for verification of information that I have provided, and/or reporting purposes.

INDIVIDUAL PLAN OF SERVICE: I further understand that the DETERMINATION OF ELIGIBILITY does not guarantee Services and that not all services will be financial in nature. I also understand that I am required to complete a formal 5 ASSESSMENT TEST to finalize the application process. I agree to work together with my assigned Career Development Specialist to develop and prepare an EMPLOYABLITY/EDUCATION DEVELOPMENT PLAN which details my individual needs and the steps I will take to achieve my goals. I understand priority is given to those who help themselves and have not previously received services. By my signature below, I indicate my agreement to abide by the policies and procedures set forth, and release of information as necessary to verify information, provide, and/or obtain services on my behalf.

______Applicant Signature Date ______Parent or Legal Guardian Signature IF Applicant if Under 18 Date