New Hanover CountyChild Care Assistance Program

Provider Intent to Participate Request

Child Care Center Name_______________________________

Address____________________________________________

Owner Name/Point of Contact_________________________

Phone Number______________________________________

Email Address_______________________________________

Center Capacity_________

Current Capacity________

Number of anticipated slots that will be allocated for participants in the NHC Child Care Assistance Program_______

Valid State Child Care License/ or GS-110 Notice of Compliance Letter issued by North Carolina Department of Child Care and Early Education: License Number#__________________________________ ******************Attach or upload a copy of the facility's license. ******************

By submitting this form to ChildCareAssist@NHCgov.com, I agree to provide full-time care for school age children Pre-K to 12 years of age for a fee of $137.50 weekly. I understand that no fees will be collected from the family in accordance with the New Hanover County Child Care Assistance program policy. I will collect a Parent Request for Assistance form for each family to whom this care is rendered. I will maintain that form and a record of the child’s attendance. Submission of those records and the NHC Child Care Provider Invoice Spreadsheet will serve as supporting documentation to New Hanover County Government for invoicing of the child care payments. Child care providers will be emailed the NHC Child Care Provider Invoice Spreadsheet and submission instructions, upon receipt of this completed intent to participate form. I attest that all information on this Intent to Participate form is true and accurate.

Signature (Owner or Designee) ______________________________

Date_________________________

After clicking the "Submit Form" button your email client will launch with this form attached. Remember to also attach a copy of your licence before sending.