This Parent Agreement form must be signed by the parent/guardian and returned to the Child Care Assistance office to verify that the parent/guardian agrees to comply with the rules and regulations of the Child Care Assistance Program as set forth below.   

CLICK HERE to download and print the Parent Agreement only.
CLICK HERE to download and print both the Parent Application and the Parent Agreement

1.    I will receive child care assistance only during the time that I am working, in training, or attending class/lab.

2.    I will provide my child care caregiver/provider with my day time phone number as well as other emergency
       contact phone numbers.

3.    I will never sign a blank attendance form.

4.    I understand and will inform my caregiver/provider that if I request additional child care services, I
       will pay for any additional services.

5.    I will notify the Child Care Assistance office in writing of any changes on my application.  This will include, but
       is not limited to, changes in my address, telephone number, and income.  I understand that I have thirty (30) days
       to report changes or my child(ren) will be terminated from the program, and I will be responsible to pay the provider.

6.    If I change caregivers/providers, I will notify the CCA office within (30) days.

7.    I will submit all income that is received.

8.    I understand that my child (ren)’s file must be considered active in order for assistance to be paid.

9.    I understand that if my child (ren)’s file is inactive, I am financially responsible for my child care services, and
       that the CCA program will not back pay.

10.    I understand that the co-payment amount is the dollar amount that I must pay per eligible child to the
         caregiver/provider each month.

11.    I understand that I am responsible for payment to the caregiver/provider if my bill is less than the co-payment.

12.    I understand that if any fraud is committed, I will repay the amount of money in question to the CCA office
         and be unable to participate in the child care program for a period of one (1) year.  If monies are not
         repaid, I will be subject to prosecution.

13.    I understand that I will be required to complete a new application if I am terminated and wish to participate again.

14.    I understand that my child is not approved for the CCA program until I receive notification from the CCA office.

15.    I understand that I will need to recertify in six (6) months to continue my assistance.