covid-19 special circumstance scholarship application for

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COVID-19 Special Circumstance Scholarship Application

for Families Requiring In-Home Child Care

District 7 HRDC

PO Box 2016, Billings, MT 59103

Fax: 406-869-2585, Drop Box: 7 North 31st Street, Billings, MT E-mail: [email protected] Phone: 406-247-4732

Serving the following counties: Big Horn, Carbon, Carter, Custer, Fallon, Golden Valley, Musselshell, Powder River, Rosebud, Sweet Grass, Stillwater, Treasure, Wheatland, Yellowstone

General Information: The COVID-19 Pandemic has created unique challenges for Montana’s families who are working to balance returning to the workforce with childcare and support needs. The scholarship is available for families with children aged 0-18. The scholarship aims to provide opportunity for families that include children or family members with special needs which may include health or safety needs requiring in-home care. This may also include foster families and kinship families with unique in-home needs.

*Note* Just because there is no ‘in person school’ is not necessarily a special circumstance. The intentof the scholarship is to provide a solution for those unique, special circumstances that cannot be served under the school or traditional child care model.

Scholarship Opportunity: A special circumstance scholarship is available to help parents offset costs for children aged 0- 18, such as individualized or specialized care, respite, increased food and supply costs for in-home childcare, increased cleaning needs, and support for remote learning.

The scholarship amount is $4000 per family and may be used for care in their home or in another provider’s home, such as a family member, a friend, or a neighbor. Scholarships must be awarded and spent by December 31, 2020 and are based on available funding. The Child Care Resource and Referral Agency may ask for additional documentation of the special circumstance.

General Terms of Eligibility: Household membership needs to be determined as well as the special circumstance needs. Your household will be asked for some basic information that supports determination of household membership at the time of application. All applications must be signed and must have a completed and signed W-9. Follow up information may be requested. Documentation is due within two weeks of the initial request. If it is not received, the application will be denied as non-responsiveness.

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COVID-19 Special Circumstance Scholarship Application

for Families Requiring In-Home Child Care

Please complete the following application and supply all documentation. Thank you. To be completed by the Parent/Guardian/Head of Household.

Head of Household Name:

Physical Address: City:

Zip: County:

School District:

Mailing Address (if different than physical address):

City: Zip:

Cell Phone Number:

Email Address:

Please list all members of the household below.

Household Member

Age Date of Birth

Social Security number Relationship to Head of Household

Head of Household

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Provide additional names, ages, social security numbers, and relationship to the head of household here:

Have you received services at HRDC 7 in the past year? Yes No

Do you give HRDC 7 permission until 12/31/20 to gather information to determine household membership? Yes No

If the answer is yes, what department? __________________________________________________

Please attach documentation for your household using one of these methods: 2019 1040 Tax Return, page 1; Federal/State/Tribal program eligibility that lists household membership (SNAP, health benefits, any assistance, housing assistance/rental agreement or other programs or benefits that may identify household members); or Child Protective information for Foster Children; or any other items that will determine your household membership.

Describe your family’s special circumstance:

You may include an additional page if you need more room or add further documentation.

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Reason for funds (check all that apply):

□ Health/safety

□ Rural – limited provider access

□ Remote Learning Support

□ Respite

□ Other special circumstance

To support health/safety determination please include medical documentation for the identified household member(s).

If you are using in-home care or in-home education support, who are you paying:

____________________________________________________________________________________

A background check is not required but strongly encouraged for in-home care. If you would like DPHHS to conduct name-based background checks for your provider, please submit an “Emergency COVID-19 Release of Information” for each individual. To receive this form, please contact Child Care Licensing at 406-444-2012, or by email, [email protected].

Please attach documentation for remote learning and enrollment with school, the school district name and address or home school verification, or special need learners with an IEP/IFSP or professional assessment documentation to verify remote learning needs.

Other documentation for respite or further special circumstance. More information may be requested by HRDC 7 staff.

I affirm that I have supplied information that is accurate, complete, and true to the best of my knowledge. I understand District 7 HRDC staff may ask for further clarification to meet the requirements for this scholarships.

Head of Household Signature:_____________________________________________________

Head of Household printed name:__________________________________________________

Date_____________________

FOR CHILD CARE RESOURCE & REFERRAL OFFICE USE ONLY:

☐ Approved ☐ Denied ☐ Payment processed

Eligibility determined by:

Date

covid-19 special circumstance scholarship application for

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