Cover Sheet

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Name of applicant: ________________________________________

Name of organization (if applicable): ___________________________

Address where family child care services or association is located:  ________________________________________________________

Applicant mailing address (if different): _________________________

Phone number: __________________   Email: __________________

County: _________________________________________________

Type of program: family child care provider family child care association

Month/year program established: ___________________
                                                              
Number of association members:  __________________

CCLD License Number (if applicable): _______________

Number of family child care providers interested in becoming a new association member or leader: ___________

Total amount requested for grant: $___________ (minimum $1,500 – maximum $5,000)

Printed Name of Person Submitting Application: __________________

Signature of Person Submitting Application: _____________________