Office of Child Care Services

							                                         Child Care Services
                                 Early Childhood Enhancement Grant
                                             Grant Deadline: April 30, 2007



Provider Name
Mailing Address
City/State/Zip Code
County
Social Security Number or
Employer ID Number
Telephone Number
Total Grant Amount Requested                $                   ($500 maximum)

Are you currently registered?            Yes        No        In-Process

Registration Date: ____________________________________

How many children are currently enrolled in your child care?
Please give a breakdown of the age groups and numbers in each age group:
 Number of children under age 3 enrolled
 Number of children age 3 years to 5 years enrolled:
 Number of children age 5 years and older enrolled:
 Are any of these children your own? How many?

Are you willing to care for children served by the Child Care Services (CCS) Direct Assistance Program?
            Yes       No

How many children served by the CCS Direct Assistance Program do you provide care for? ______



Project Description: How do you plan to use grant funds?
Please list the equipment you are requesting, as well as actual prices. Do not forget tax or shipping
cost where applicable. If available, attach catalog pictures of the items requested.


                                Compliance Item                                          Total Cost
   Example: Cribs                                                                                $499.95




                                        Total                                        $


I hereby apply for an Early Childhood Enhancement grant from the Division of Child Care Services. This
grant is intended to purchase high-quality equipment for my child care facility. I understand that I will be
obligated to repay 50% of the grant award if I do not continue to provide child care and/or maintain my
registration for a minimum of one year. I also understand that if I receive a grant, it will be paid to me on a
reimbursement basis, after I provide verification of purchase.

I certify that the information I have provided in this application is true and correct, to the best of my
knowledge.




       Authorized Signature                                                                           Date