Date Total Dollars Requested Child Care Name Type of Facility - Select -Family Based Center Faith Based Employer Based Address City State Zip Contact Person Phone Email Years in Operation Total number of infants (6wks-12mo) you currently serve? Total number of toddlers (12mo-24mo) you currently serve? Total number of pre-school (24mo-5yrs) you currently serve? Total number of school-age (5yrs-12yrs) you currently serve? Describe your plans to expand your child care business and how you will use the requested amount of funds. How many additional infants will you serve by expanding? How many additional toddlers will you serve by expanding? How many additional pre-schoolers will you serve by expanding? How many additional school age children will you serve by expanding? Are you a Parent Aware rated provider? - Select -Yes No If yes, when was your rating complete? What star did you pursue? Please attach proof of rating completion. If no, have you signed a contract to begin the rating process? - None -Yes No When is your rating scheduled to be complete? What are your current hours of operation? Do you require families to use a minimum number of hours per week? Will your hours of service change with your expansion to accommodate families with shift work and extended work hours, if not doing so already? Do you serve children with disabilities or special needs? Please provide any additional comments to support your request for funding. Budget, Timetable and Additional Funding Sources Attachments Attach estimate or bid Copy of your childcare license Copy of your Business Plan new child care businesses only Copy of your cash flow projections new child care businesses only If applicaple, copy of your contractor's license for the project Please attach a picture for any unique or expensive items that might be questioned by the review committee Additional picture Additional supporting documents CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question 4 + 7 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank