Join Us on the Court! Registration is Open for Our Pickleball Fundraising Tournament. Learn More

Child Care Scholarship Program Family Application

Complete all sections of this application and include any documentation requested.

DURHAM ONLY Scholarship Application and Consent Form Combined (English)

DURHAM ONLY Scholarship Application and Consent Form Combined (English)

Primary Applicant

Race
Per
Per
Enrolled
School Type
School Name

Other Parent/Guardian

(lives with the applicant and shares financial responsibility for a child/children for whom this application requests a scholarship)
Race
Per
Per
School Name

Supporting Eligibility Documentation

With this application, the primary applicant and other parent/guardian (if applicable) named above must submit the following documentation of activity and income listed above for the purposes of eligibility determination. If there are questions about any of these items or one of the forms listed below is needed, please call (919) 403-6950 and ask to speak to a Scholarship Specialist.

Household Information

A household, for the purposes of this application, is considered the primary applicant and other parent/guardian (if applicable) residing at the street address listed below and any of their dependents. A dependent is someone who relies on the primary applicant and/or other parent/guardian for financial support, such as children claimed on a tax return or an elderly disabled parent.
Street Address
Apt/Unit #
City, State and Zip
County
Mailing Address: (if different from above)
Apt/Unit #
City, State and Zip
County
I agree to receive text messages at any of the cell phone numbers listed above.

Household Dependents

Relationship to Primary Applicant or Other Parent/Guardian
Office Use Only: X = Not Counted in Household
Relationship to Primary Applicant or Other Parent/Guardian
Office Use Only: X = Not Counted in Household
Relationship to Primary Applicant or Other Parent/Guardian
Office Use Only: X = Not Counted in Household
Relationship to Primary Applicant or Other Parent/Guardian
Office Use Only: X = Not Counted in Household
Relationship to Primary Applicant or Other Parent/Guardian
Office Use Only: X = Not Counted in Household
Relationship to Primary Applicant or Other Parent/Guardian
Office Use Only: X = Not Counted in Household
Relationship to Primary Applicant or Other Parent/Guardian
Office Use Only: X = Not Counted in Household

Applying Child Information 1

Birth certificate or other proof of age attached
Gender
Weekly Hours of Care Needed
Race
*referrals provided if less than 4-star care and/ or ineligible to be considered for scholarships
Child currently enrolled at this site?
Additional Information (check all that apply)
Does anyone other than the Primary Applicant or Other Parent/Guardian listed on page 1 of this application share financial responsibility for this child, such as providing child support or claiming this child on his/her taxes?
Full Name

Applying Child Information 2

Birth certificate or other proof of age attached
Gender
Weekly Hours of Care Needed
*referrals provided if less than 4-star care and/ or ineligible to be considered for scholarships
Child currently enrolled at this site?
Checkboxes
Additional Information (check all that apply)
Does anyone other than the Primary Applicant or Other Parent/Guardian listed on page 1 of this application share financial responsibility for this child, such as providing child support or claiming this child on his/her taxes?
Full Name

Applying Child Information 3

Birth certificate or other proof of age attached
Gender
Weekly Hours of Care Needed
*referrals provided if less than 4-star care and/ or ineligible to be considered for scholarships
Child currently enrolled at this site?
Checkboxes
Additional Information (check all that apply)
Does anyone other than the Primary Applicant or Other Parent/Guardian listed on page 1 of this application share financial responsibility for this child, such as providing child support or claiming this child on his/her taxes?
Full Name

Parent/Guardian Participation Agreement

The primary applicant and, if present in the home, other parent/guardian should read and initial each statement below, then sign and date this form at the bottom. For any item on this page requiring clarification, please reach out to any member of the Scholarship team at FamilyScholarship@earlyyearsnc.org or 919-403-6950 x2108.

I understand that my application to the Scholarship Program is part of my eligibility review for Scholarship service but does not guarantee service. I understand that my Scholarship Specialist will inform me of the results of my eligibility review once I’ve submitted all required documentation.

If awarded Scholarship service, I understand that I will receive a Notice of Scholarship Award containing the details of my service including but not limited to the dates and amount of care, child care facility information, parent fees, and contact information for my assigned Scholarship Specialist. I am aware that if the details of my award should change, I will be issued subsequent notices
containing updated information about my award. I understand that any child care I use that is not covered in an initial or subsequent Notice of Scholarship Award will be entirely my financial responsibility.

I accept responsibility for keeping the details included in my Scholarship application up to date with my Scholarship Specialist, including any changes in employer or employment status, hours devoted to school or work, income of any type, and household size and make-up. I understand that any significant change in parent/family circumstances may affect the type of scholarship, if any, I am eligible for, and failure to report such a change may result in termination of services.

I agree to remain reachable throughout the term of any Scholarship service my family may be awarded and respond in a timely manner to any request for additional documentation by my Scholarship Specialist. I understand that failure to respond, to
provide requested documentation, or to make updates to my eligibility details may result in termination of Scholarship service or full or
partial repayment of the scholarship paid by Early Years to my provider on my child’s behalf.

I understand that, should I be awarded Scholarship service, monthly parent fees assigned to me will be based on a percentage of my income, as calculated by documentation submitted for my eligibility review, and that I would be expected to pay these fees directly to my child care provider on the schedule my provider would set. Should I begin or end care mid-month, I understand that my provider should divide my parent fee by 21.67 to reach a daily rate for the purposes of prorating the fee for that month. I realize that nonpayment of parent fees to my child care facility may result in termination of my Scholarship service there and that Scholarship service cannot be transferred to any other child care program until all outstanding child care fees are paid in full.
If awarded Scholarship service, I agree to bring my child regularly to child care utilizing the amount of care in my Notice of Scholarship Award and to notify my Scholarship Specialist if my child’s absence from care exceeds 5 business days in any month of Scholarship service. I further agree to give my child care provider and Scholarship Specialist two full weeks’ notice, preferably in writing,
prior to removing my child from care, realizing that failure to do so could delay transfer of Scholarship service to another provider.

I understand that child care providers are business owners or operators. If awarded Scholarship service, I understand that my enrollment at a particular site makes me subject to the same rules, hours, paperwork, fees, policies, etc. as families paying
privately for care at the same facility.

I confirm that I am not currently using any other form of child care subsidy, scholarship, or financial assistance to pay for child care and that if such assistance were to be offered, I would inform my Scholarship Specialist right away.

I understand that failure to follow the items I have initialed in this Parent Participation Agreement could jeopardize my continued eligibility for Scholarship service.

By signing below, I affirm that the information provided in this application is true, accurate and complete. I understand that any information provided in this application may be shared with and released to third parties, including but not limited to Durham and Orange County Departments of Social Services, Head Start/Early Head Start, NC Pre-K and other local subsidy partners. I hereby authorize and consent to the release and sharing of such information by Early Years to and with third parties. On behalf of the child, and in my individual capacity, I hereby release Early Years, its employees and agents from any liability or damages that may result from the release or sharing of such information, including liability or damages resulting from possible inaccuracies, errors or other
inadvertent occurrences relating to such information or the maintenance of such information.

CONSENT FOR EXCHANGE OF INFORMATION

Parent
Parent
First Name
Last Name
Child
Child
First Name
Last Name

Early Years has accepted your application for the Child Care Scholarship Program. As part of your eligibility
review for Scholarship services our office may need to exchange information with other agencies offering child
care assistance to reduce duplication of services. You have agreed to keeping details included in your application
up to date with your assigned Scholarship Specialist which includes any changes in employer or employment
status, hours devoted to school or work, income of any type, and household size and make-up. By signing this
form you authorize and consent to the exchange of such information by Early Years to and with third parties.

We may need to exchange information with the following agencies:
• Department of Social Services (DSS)-TANF/Work First, Childcare Subsidy, Medicaid, SNAP
• Durham Public Schools
• Durham’s Partnership for Children
• Families and Communities Rising
• Others

As parent/guardian of this child, I give my consent for Early Years staff and agencies listed above to provide the above services and exchange information about my child with the agencies/providers listed as needed. I
understand that this consent is voluntary, will be faxed or scanned to the above agency(ies) to show my consent for this release, and is valid for one year or until I cancel this release in writing.
The Early Years Child Care Scholarship program is made possible by funding from Durham’s  Partnership for Children – a Smart Start initiative, University of North Carolina at Chapel Hill, United Way of the Greater Triangle, the Towns of Chapel Hill and Carrboro, St. Thomas More Church, and private contributions.