For
Child Care
Providers

Resource & Referral Program

Cleaning and Supplies for Child Care Providers (CSCP) Self-Certification Form

Funding, for providers within our service area, is available for cleaning, and other supplies for licensed and license-exempt center and home-based providers who are operating an Early Learning and Care (ELC) program and are open, or are soon to be open, to provide child care during the COVID-19 state of emergency for children of essential workers, at-risk populations, and children with disabilities or special health care needs where the child’s individualized education plan (IEP) or individualized family service plan (IFSP) includes ELC services. Please complete the form below and we will contact you regarding your eligibility.

[?] Licensed Home & Center: Please enter your licensed capacity or the number of children you served(enter the larger of the two).

Licensed Exempt Centers: Please enter your capacity of children.

Licensed Exempt Homes: Please enter the total number of subsidized children you serve at any single time.
 
Provider Type
Center:
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Home Based:
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Certification
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[?] If you never closed, please type “Never Closed”
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[?] Please check one of the boxes to demonstrate your interest. If you are interested in receiving both supplies and the stipend funding, please check off the “Receiving Both” box.
 

I understand, as a provider, that this self-certification form is a requirement to receive CSCP funds, supplies, or both to serve essential workers and/or at-risk populations during the COVID-19 pandemic. As stated on this form, my program currently is open or will be open by the date specified and the funds and/or supplies will be used solely for these restricted purposes.

 
 
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