Knud Hansen Complex Bldg. A • 1303 Hospital Ground • St. Thomas, Virgin Islands 00802 • (340) 774-0930 ph • (340) 774-4673 fax 3011 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 773-2323 ph • (340) 719-9763 fax COVID-19 Child Care & Development Block Grant INFORMAL CARE Provider APPLICATION (Family, Friends, and Neighbor) Last four check stubs if paid weekly or Employer’s Letter Verifying employment (full or part time) and rate of pay hourly wage Date of the Application: An Informal Provider, who expresses an interest in the program, must adhere to the following criteria and provide the necessary documents listed: 1. A copy of proof of physical address in U.S. Virgin Islands: (Only 1 below) a. Rental Lease Agreements b. Utility Bills c. Proof of Ownership 2. A copy of valid ID (At least one of the following): a. Driver’s License b. Passport c. Bureau of Motor Vehicle V.I. Non-Driver ID d. Permanent Resident Card 3. Proof of U.S. Citizens/Residency (At least one of the following) a. U.S. or V.I. Birth Certificate b. U.S. Passport c. Permanent Resident Card 4. A copy of Social Security Card 5. V.I. Police Department Criminal Records Check 6. V.I. Sex Offender Registry Clearance 7. Proof of income- (Last two check stubs if paid twice a month. GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services “Working Together to Make a Difference” Office of Child Care & Regulatory Services 2 Revised 9/25/2020 or per annum (Income Eligibility Determined on a case by case if over the established V.I. income thresholds for Child Care Block Grant) Note: V.I. Police Department Criminal Records Check and V.I. Sex Offender Registry Clearance is required for family members of the parent/guardian and child(ren) who are selected to be the Informal Provider. Note: To be deemed eligible to serve as an Informal Provider, you must:  Be eighteen (18) years or older.  Not live in the same household as the parent/guardian or child  Not have been convicted of a felony consisting of murder, child abuse or neglect, crimes against children (including child pornography), spousal abuse, crime involving rape or sexual assault, kidnapping, arson, physical assault, or a drug-related offense committed during the preceding 5 years, and cannot have been convicted of a violent misdemeanor committed as an adult against a child. Self-Attestation of Environmental/Home Factors Note: If at any time, the child(ren) will be cared for in your home environment you must complete the following table. By placing your signature in the signature space below, you are attesting or indicating, your home is in compliance with the physical environment, fire safety, and other general safety requirements. You may also be subject to unannounced visits to your home by the Department of Human Services Child Care Licensing Specialist. Providers Information Provider Name: Date of Birth: SS # City/Town: ___ State: Zip Code: Physical Address: City/Town: ___ State: Zip Code: Mailing Address: City/Town: ___ State: Zip Code: Email Address: Telephone Number: Cell Number: Hours of care: Days of care: 3 Revised 9/25/2020 Codes for Relationship of Participant to Caregiver (1) Family (3) Neighbor (2) Friend (4) Informal Provider NOT related to Parent/Guardian or Child Account for all other persons who may come in contact with the enrolled child(ren) in your care within your home setting. Parent’s Name Child’s Name Birthdate Gender (M/F) Relationship (Codes Below) Case Number Provider Fee Physical Environment Yes No Adequate floor space Surface clean, in good repair Adequate ventilation Warm and cold running water Working indoor toilets accessible Enough furniture and equipment for children Working telephone in home Fire Safety Working smoke detector Lockable interior doors can unlock from outside Heating/cooling devices vented, protected by guards, kept clear of combustible Stairways, hallways exit unobstructed Electrical cords in good condition General Safety/Sanitation Home and furnishings present not hazardous All toxic substances out of reach Glass doors clearly marked at a child’s level Non-permanent barriers on stairs, ramps, balconies, porches, Electrical outlets accessible to children are covered Working flashlight available Adequate, safe outdoor play area adjacent to or within walking distance of home Garbage properly covered, stored and emptied First aid supplies accessible Individual towels and washcloths or disposable towels and washcloths Drinking water available 4 Revised 9/25/2020 Name Relation to caregiver (Codes Below) Birthdate Gender Extent of contact At home during care Relation of others in the home to a caregiver Gender Extent of contact At home during care (1) Spouse (2) Son/Daughter (3) Brother/Sister (4) Friend (5) Neighbor (6) Other(specify)_______ (1) Male (2) Female (1) No contact (2) Some contact (3) Frequent contact (1) At Home (2) Not at Home I, _________________________________, attest that all the information provided in this (Print Your Name) Informal Provider Application is the truth, to the best of my knowledge. _______________________________________ ____________________ Signature of Informal Provider Applicant Date Note: Application must be notarized before you submit it to DHS Office of Child Care and Regulatory Services SUBSCRIBED AND SWORN TO before me this ____ day of ______ NOTARY PUBLIC