Special Accommodation Grants (SAG) is sponsored by Vermont Agency of Human Services, Department for Children and Families. Assists licensed specialized child care programs in supporting the safe and successful inclusion of children with special needs within their care programs.

Special Accommodations Grant (SAG) Child Development Division Special Accommodations Grant (SAG) September 2025-August 2026 The Agency of Human Services, Department for Children and Families, Child Development Division (referred to as the “State”) invites Vermont Regulated Specialized Child Care Programs to apply for funds to support the safe and successful inclusion of one or more children in their program.

These funds are designed to support the safe and successful inclusion, access, and participation of one or more children with identified needs in your group or classroom. The grant funds are intended to cover any gap left after all entitled or eligible services are provided for the child(ren).

You have the flexibility to apply for grant funds to purchase the following: Specialized materials and/or supplies (See RFGA for details) Consultation, training, or coaching for your child care staff tailored to support the child/children's needs Inclusion Support Staff to provide additional staffing.

If your application is approved, your program may receive funding for an additional staff person to support the safe and successful inclusion of one or more children. This Inclusion Support Staff member is not permitted to count toward licensing ratios. Their role is specifically to provide individualized assistance that goes above and beyond your required staffing.

Specialized Child Care Programs (SCC) must be in compliance with their SCC Agreement and in good standing with Vermont child care licensing regulations. If you need more information on the status of your Specialized Child Care Agreement, please contact your Regional Specialized Child Care Coordinator.

SCC programs may apply on behalf of one or more children with identified needs who require additional support to access or remain enrolled in their program. Child care programs must complete the SAG application in partnership with the child’s team, which includes the child’s parent/caregiver and the professionals working together to support the child’s successful inclusion within the program.

Step 1: Review and Prepare Your Application ✔️ Review the RFGA and Frequently Asked Questions Read the Request for Grant Applications (RFGA for SAG) for details about timelines, eligibility, required documentation, and grant specifications. ✔️ Meet with the Parent or Legal Guardian Review the CIS SAG Parent/Guardian Consent Form together. Both the provider and the parent/legal guardian must sign the form.

List the names of professionals on the child’s support team who are contributing to the application. Upload the signed form with your application. ✔️ Request the Service/Health Provider Letter of Support Email the SAG Service/Health Provider Letter of Support Form to a provider who can speak to the child’s needs.

Once submitted by the provider, the form will be automatically uploaded into JotForm and linked to your application. Step 2: Required Attachments ✔️ CIS SAG Parent/Guardian Consent Form Upload one signed form for each child named in the application. ✔️ SAG Service/Health Provider Letter of Support Form This form will be submitted directly by the provider via JotForm.

Only upload the PDF version if the provider gave it to you directly.

Letters completed by the child care program staff will not be accepted Submit at least one of the following, dated within the past 6 months: CIS One Plan (active or interim plan) Individualized Education Plan (IEP) Educational Support Team (EST) Plan Mental Health/Behavorial/Health Related Plan If no formal plan is available, include referrals, screenings, or evaluations that demonstrate and show the child’s need for support.

✔️ Certificate of Insurance • Must meet the insurance requirements outlined in Attachment C, Section 8 of • Must be signed and dated within the last six (6) months. ✔️ Unique Entity ID (UEI) Unique Entity ID (UEI) – Applicants are required to have a UEI assigned by registering on SAM. gov .

Suppose you have requested a UEI but have not yet received it. In that case, you will need to provide a copy of the email from SAM. gov showing that you have requested the UEI and/or the help desk email confirmation regarding any follow-up on the issuance of a UEI.

If your UEI is in process, please upload a signed and dated Certification of Suspension and Debarment. If you have a UEI, but your SAM registration is not active, please upload a signed and dated Certification of Suspension and Debarment. Questions and Technical Support: 🧾 SAG Weekly Applicant Information Session Join our weekly virtual Q&A to ask questions or get help with your SAG application.

🗓 Day: Every Thursday (unless otherwise posted) 🕛 Time: 12:00 PM – 1:00 PM 📍 Location: Microsoft Teams (virtual) 🔗 Join the Meeting Online Click here to join the meeting now Meeting ID: 272 197 492 755 7 Dial: +1 802-552-8456,,443062859# (United States – Montpelier) Phone Conference ID: 443 062 859# Find a local dial-in number Before You Proceed with the Application Before proceeding with the application, please note the following: The application could take 30 to 60 minutes to complete.

You can save and continue later at any time by clicking the Save button at the bottom of the page. In order to save, you will be required to create a JotForm account (if you don't already have one) using an existing Google or Facebook account, or your email. Please have the Required Attachments (see previous page) saved to your computer and ready to upload into this application.

Please verify the following: * I have read and reviewed the RFGA CDD- SAG 9-5-2025. I have a completed CIS Parent/Guardian Authorization Consent form for each child to be named in this application. You cannot move forward with this application until you have reviewed the RFGA .

You cannot move forward with this application until you have received parent/guardian consent for each child named in the application. To get consent, please have the parent(s)/guardian(s) complete the CIS Parent/Guardian Authorization Consent Form .

Organization/Program Information Fully Approved Denied Partially Approved Withdrawn Pending/Incomplete The license number can be found on your license certificate that is posted on the wall in the program. If you are unsure of your ID #, you can search for it on the Vermont Secretary of State's website at https://bizfilings. vermont.

gov/online/BusinessInquire/. State of Vermont Vision Supplier ID * Please see the FAQs for instructions of how to locate at https://www. vermontbusinessregistry.

com/BidPreview. aspx? BidID=57470 Child Care Program Name * Enter your program name as listed in BFIS or CDDIS.

If you are a registered family child care home provider, list your own name (e.g., Jane Doe). Licensee Organization Name Enter the name of the organization or person who receives the funds/owns the program, if different from the Program Name.

Afterschool Child Care Program (ASP) Center Based Child Care and Preschool Program (CBCCPP) Licensed Family Child Care Home (FCCH) Registered Family Child Care Home (FCCH) Who is the Point of Contact? Responsible for answering questions regarding this application information. Point of Contact's Name * Point of Contact's Job Title * Point of Contact's Phone Number * Please enter a valid phone number.

Point of Contact's Email * Organization/Program's Physical Address * JDO- Caledonia/S. Essex St. Johnsbury ADO- Franklin/Grand Isle St.

Albans HDO- Orange/N. Windsor- Hartford NDO- Orleans/N. Essex- Newport SDO- S.

Windsor/N. Windham Springfield Is your program's mailing address the same as your physical address? * Organization/Program's Mailing Address (if different than physical) * Child Care Program Details...

Does your program have Specialized Services Status? * If your program does not have Specialized Child Care status, please reach out to your Specialized Child Care Coordinator at the to find out more about becoming a Specialized Child Care Program. Please do not continue with this application until you have contacted your Specialized Child Care Coordinator.

Is your program a current Universal Pre-K program? * Accepts Child Care Financial Assistance * Does your program currently have an active Special Accommodation Grant (SAG)? Please tell us which classroom the grant is currently supporting, how many children are being supported, and give a brief description of how the grant is working for your program at this time.

* ⚠️Reminder for Renewal Applications If you are reapplying for a child who currently has a SAG grant, please note that there is not a separate renewal application. For each question, think about the progress you have made and describe your answers from that perspective.

The strategies currently in place to support the child An explanation of how these strategies are working and the improvements observed Any new or adapted practices your program is using to further strengthen inclusion A clear explanation of why continued funding is necessary to maintain or enhance support for the child How many children are part of this application?

* Please upload the signed CIS Parent/Guardian Consent Form for child 1. * Browse Files Drag and drop files here Child 1 Application Status Approved-met scoring criteria Denied-did not meet scoring criteria Approved-then withdrew Incomplete- could not score application JDO- Caledonia/S. Essex St.

Johnsbury ADO- Franklin/Grand Isle St. Albans HDO- Orange/N. Windsor- Hartford NDO- Orleans/N.

Essex- Newport SDO- S. Windsor/N. Windham Springfield - Month - Day Year Date Picker Icon Child 1 Primary Physical Address * Child 1 - Parent/Legal Guardian's Name * Is the parent/legal guardian’s primary physical address different than the child’s?

* Child 1 - Parent/Legal Guardian's Primary Physical Address * Child 1 - Parent/Legal Guardian's Email * Child 1 - Parent/Legal Guardian's Phone Number * Please enter a valid phone number. Child 1-Does the child/family receive Child Care Financial Assistance? * Child 1-Under what primary Child Care Financial Assistance Program (CCFAP) service need?

* Parent with special health needs Attending school or training Child with special health needs Child 1-Does this child/family have an open or custody case with the Family Services Division (FSD)?

* No, but history of FSD involvement Yes, family is working with FSD for support Yes, open case and child remains in the family's custody Yes, open case and the child is in the care of a relative Yes, child is in foster care Child has been adopted through FSD Child 1 -Has the child received a placement change within the last year (e.g., entering foster care, changing foster homes, or entering reunification)?

* No, placement has remained stable for at least a year. Yes, one placement change in the last year. Yes, two or more placement changes in the last year.

Unknown Child 1- Family Services Worker's Name * Family Services Worker's Phone Number Please enter a valid phone number. Family Services Worker's Email * Child 1-Does the child/family have health insurance? * Medicaid Private Both Medicaid and Private Uninsured Child 1 -Is this the child's first time in a child care setting?

* Child 1-Has this child previously been required to leave a child care setting due to the program's inability to meet the child's needs? * Child 1- Please explain. * Child 1-Is this child currently attending your program?

* Yes No - Unable to access without additional supports. Child 1-When did this child begin attending your program? * - Day - Month Year Date Picker Icon Child 1-Have the child’s needs affected their enrollment or daily participation in your program If yes, please indicate how.

* No impact on enrollment Some adjustments have been made, but enrollment is stable Reduced hours Reduced days Reduced both hours and days Child is at risk of losing placement without additional support Child not able to attend childcare Staffing Ratio is at capacity Transitioning to a new classroom or group Other Child 1- What age group is the child transitioning too?

* Toddler Preschool School age FCCH mixed aged group Other mixed aged group Child 1- Please describe any barriers or challenges that make it difficult for this child to fully attend or participate in your program, and what supports or changes would help. * Child 1-Has this child been supported previously by SAG funding in your program?

* Child 1-Start Date of Last SAG Received * - Month - Day Year Date Picker Icon Child 1-End Date of Last SAG Received * - Month - Day Year Date Picker Icon Please enter the number of hours the child currently attends your program. All fields must be filled. Enter zeros as needed.

Early Childhood Education Program Child 1-Is this child 3 or older? Child 1-Does the child receive Universal Pre-K (UPK) funding (for 10 hours a week) in your program? * Child 1-Does the school district or supervisory union (LEA) provide any special education or related services to the child during their day (e.g., IEP services, consultation, specialty providers)?

* Child 1-Has this child been referred for a special education evaluation or services? Child 1-Why does the child not currently receive special education services or support from their school district? We have not discussed special education referrals with the family.

Family refused consent for referral or did not engage in the evaluation process. Child has been referred and is pending an evaluation. Child was evaluated and determined not eligible.

Child's child care is not in the same district as the school. Child 1-Is your child care program located in the same school district as the child's town of residence? Child 1- Name of the child's elementary school * Please upload the Service/Health Provider Letter of Support if it was not submitted by the provider through the JotForm process .

Please upload the Service/Health Provider Letter of Support here: Browse Files Drag and drop files here Child 1- Does the child have a current medical, developmental, or mental health condition or diagnosis?

* Child 1-The child’s condition or diagnosis is (check all that apply): * Behavior challenges Developmental delay Global Developmental Delay Autism (ASD) ADHD Down Syndrome Cerebral Palsy Vision loss (including, low vision, CVI, blindness) Hearing loss/deafness Health condition (please describe below, e.g., epilepsy, diabetes) Genetic condition (please describe below) Learning disability (please describe below) Other, please describe below Child 1- Please explain how the child’s diagnosis or condition contributes to the need for additional staffing, supervision, or other supports in your program.

* Child 1-Are there medical or personal care needs that require additional adult support during the day (medication, feeding, toileting, mobility)? If yes, please describe the supports your program provides to help the child participate fully. * Child 1-Please explain.

* Child 1-How often do the child’s needs (behavioral, emotional, medical, or personal care) raise safety concerns or require additional supervision that affects their participation in the classroom.

* Rarely (less than once per month) → 0% Occasionally (a few times per month) → 20% Sometimes (1–2 times per week) → 40% Often (3–5 times per week) → 60% Very often 3-5x (daily) → 80% Almost all the time the child is in care → 100% Child 1-What unsafe behavior does the child engage in?

Please select all that apply: * eloping/running away biting hitting kicking throwing objects verbal threats property destruction head banging other self-injury other behavior causing harm to others none Child 1-Please describe the challenges you are experiencing with the child in the program (e.g., what is happening, how often, etc.).

* Child 1-Is the child currently able to engage in developmentally appropriate relationships with peers? * Child 1-Peers-Please explain. * Child 1-Is the child currently able to form developmentally appropriate relationships with adults?

* Child 1- Adults - Please explain. * Child 1-Is the child currently able to self-regulate their behavior in a developmentally appropriate way (e.g., with adult support)? * Child 1-Self Regulate- Please explain.

* Child 1-At this time, how often is there communication between your program and the child's support team (ex. , service providers, family, community partners, public school) around the resources needed to support the child in care? * Child 1-Please describe your engagement with the child's parent/guardian.

* Child 1- What strategies has your program tried?

* Referrals for services Training for staff Consultation/coaching for program/classroom/teachers Classroom self-assessment of universal practices to support SEL development Additional staffing in classroom Modifying routines or reducing frequency of transitions Visual Schedule or other visual supports Visual timers Social stories and/or books Environmental modifications Safety equipment (e.g., door alarms) Increasing opportunities for sensory regulating activities in daily routine Changes to transition strategies (e.g., staggering/grouping, using music, assigning roles) Co-regulation strategies Declarative language strategies Sensory breaks Heavy work (child pushes, pulls, or carries, heavy things to regulate) Redirection to safer alternatives or preferred activities Other (please describe) Child 1-How long has your program been trying these strategies?

* Child 1-Please describe other strategies you have tried to support this child's inclusion in the classroom. * Please upload a copy of the child’s plan (ex. , IEP, One Plan, 504, Treatment Plan) updated within the last six (6) months.

Please submit a screening or assessment if the child does not have a plan. * Browse Files Drag and drop files here Child 1-What services does the child receive?

* CIS Early Intervention / Developmental Education CIS Family Support Home Visiting CIS Early Childhood and Family Mental Health Consultation CIS - Home Visiting, Nursing Supports Early Childhood Special Education (formally EEE) School-Age Special Education Mental Health Services/Counseling Head Start/Early Head Start Children’s Personal Care Services Speech and Language therapy Occupational Therapy Deaf and Hard of Hearing support Vision Loss/Visual Impairment support Home Health Autism Consult Applied Behavior Analysis (ABA) Services Personal Care Assistance (PCA) UVM - Early Intervention Project of VT (formally the ITEAM) Other None Child 1-Does this child currently receive any direct supports at the child care program?

* Child 1-If this child receives direct supports at your program, please explain what those supports look like, who provides them, and how often they occur (e.g., number of times per week, duration, or consistency) * Child 1-Are there any barriers your program experiences to connecting or referring to service providers? Child 1-What services or support has your program accessed to support this child/classroom?

CIS Consultation and Education Seed and Sew training and/or coaching Early MTSS training and/or coaching Consultation from public school SPARQS coaching CIS Nursing CIS Early Intervention CIS Specialized Child Care Supports Other coaching, consultation, or specialized training Other Please upload the signed CIS Parent/Guardian Consent Form for child 2.

* Browse Files Drag and drop files here Child 2 Application Status Approved-met scoring criteria Denied-did not meet scoring criteria Approved-then withdrew Incomplete- could not score application JDO- Caledonia/S. Essex St. Johnsbury ADO- Franklin/Grand Isle St.

Albans HDO- Orange/N. Windsor- Hartford NDO- Orleans/N. Essex- Newport SDO- S.

Windsor/N. Windham Springfield - Month - Day Year Date Picker Icon Child 2 Primary Physical Address * Child 2 - Parent/Legal Guardian's Name * Child 2-Is the parent/legal guardian’s primary physical address different than the child’s? * Child 2 - Parent/Legal Guardian's Primary Physical Address * Child 2 - Parent/Legal Guardian's Email * Child 2 - Parent/Legal Guardian's Phone Number * Please enter a valid phone number.

Child 2-Does the child/family receive Child Care Financial Assistance? * Child 2-Under what primary Child Care Financial Assistance Program (CCFAP) service need? * Parent with special health needs Attending school or training Child with special health needs Child 2-Does this child/family have an open or custody case with the Family Services Division (FSD)?

* No, but history of FSD involvement Yes, family is working with FSD for support Yes, open case and child remains in the family's custody Yes, open case and the child is in the care of a relative Yes, child is in foster care Child has been adopted through FSD Child 2-Has the child received a placement change within the last year (e.g., entering foster care, changing foster homes, or entering reunification)?

* No, placement has remained stable for at least a year. Yes, one placement change in the last year. Yes, two or more placement changes in the last year.

Unknown Child 2-Family Services Worker's Name * Child 2-Family Services Worker's Phone Number * Please enter a valid phone number. Child 2-Family Services Worker's Email * Child 2-Does the child/family have health insurance? * Medicaid Private Both Medicaid and Private Uninsured Child 2-Is this the child's first time in a child care setting?

* Child 2-Has this child previously been required to leave a child care setting due to the program's inability to meet the child's needs? Child 2-Is this child currently attending your program? * Yes No - Unable to access without additional supports.

Child 2-When did this child begin attending your program? * - Month - Day Year Date Picker Icon Child 2-Have the child’s needs (medical, behavioral, developmental, or personal care) affected their enrollment or participation in your program? (For example, requiring staffing changes, safety adjustments, or reduced hours/days.)

No impact on enrollment Some adjustments have been made, but enrollment is stable Reduced hours Reduced days Reduced both hours and days Child is at risk of losing placement without additional support Child not able to attend childcare Staffing Ratio is at capacity Transitioning to a new classroom or group Other Child 2-What age group is the child transitioning to?

* Toddler Preschool School age FCCH mixed aged group Other mixed aged group Child 2-Please explain the barriers or challenges to having this child attend your program. * Child 2-Has this child been supported previously by SAG funding in your program?

* Start Date of Last Grant Received * - Month - Day Year Date Picker Icon End Date of Last Grant Received * - Month - Day Year Date Picker Icon Please enter the number of hours the child currently attends your program. All fields must be filled. Enter zeros as needed.

* Early Childhood Education Program Child 2-Is this child 3 years or older? * Child 2-Does the child receive Universal Pre-K (UPK) funding (for 10 hours a week) in your program? * Child 2-Are they receiving special education or support services from their school district or supervisory union (LEA)?

* Child 2-Has this child been referred for a special education evaluation or services? * Child 2-Why does the child not currently receive special education services or support from their school district? * We have not discussed special education referrals with the family.

Family refused consent for referral or did not engage in the evaluation process. Child has been referred and is pending an evaluation. Child was evaluated and determined not eligible.

Child's child care is not in the same district as the school. Child 2-Is your child care program located in the same school district as the child's town of residence? * Child 2-Name of the child's elementary school * Please upload the Service/Health Provider Letter of Support if it was not submitted by the provider through the JotForm process .

Please upload the Service/Health Provider Letter of Support here for child 2: Browse Files Drag and drop files here Child 2-Does the child have a current medical, developmental, or mental health condition or diagnosis?

* Child 2-The child’s condition or diagnosis is (check all that apply): * Behavior challenges Developmental delay Global Developmental Delay Autism (ASD) ADHD Down Syndrome Cerebral Palsy Vision loss (including, low vision, CVI, blindness) Hearing loss/deafness Health condition (please describe below, e.g., epilepsy, diabetes) Genetic condition (please describe below) Learning disability (please describe below) Other, please describe below Child 2- Please share any diagnoses, conditions, or developmental information.

* Child 2-Does the child have medical or personal care needs (medication, feeding, toileting, mobility, etc.) that require adult support that is significantly above and beyond what is typical for their age group? * Child 2-Please explain.

* Child 2- How often do the child’s needs (behavioral, emotional, medical, or personal care) raise safety concerns or require additional supervision that affects their participation in the classroom or the safety of peers/staff?

* Rarely (less than once per month) → 0% Occasionally (a few times per month) → 20% Sometimes (1–2 times per week) → 40% Often (3–5 times per week) → 60% Very often 3-5x (daily) → 80% Almost all the time the child is in care → 100% Child 2-What unsafe behavior does the child engage in?

Please select all that apply: * eloping/running away biting hitting kicking throwing objects verbal threats property destruction head banging other self-injury other behavior causing harm to others none Child 2-Please describe the challenges you are experiencing with the child in the program (e.g., what is happening, how often, etc.).

* Child 2-Is the child currently able to engage in developmentally appropriate relationships with peers? * Child 2-Peers-Please explain. * Child 2-Is the child currently able to form developmentally appropriate relationships with adults?

* Child 2-Adults-Please explain. * Child 2-Is the child currently able to self-regulate their behavior in a developmentally appropriate way (e.g., with adult support)? * Child 2-Self Regulation- Please explain.

* Child 2-At this time, how often is there communication between your program and the child's support team (ex. , service providers, family, community partners, public school) around the resources needed to support the child in care? * Child 2-Please describe your engagement with the child's parent/guardian?

* Child 2-What strategies has your program tried?

* Referrals for services Training for staff Consultation/coaching for program/classroom/teachers Classroom self-assessment of universal practices to support SEL development Additional staffing in classroom Modifying routines or reducing frequency of transitions Visual Schedule or other visual supports Visual timers Social stories and/or books Environmental modifications Safety equipment (e.g., door alarms) Increasing opportunities for sensory regulating activities in daily routine Changes to transition strategies (e.g., staggering/grouping, using music, assigning roles) Co-regulation strategies Declarative language strategies Sensory breaks Heavy work (child pushes, pulls, or carries, heavy things to regulate) Redirection to safer alternatives or preferred activities Other (please describe) Child 2-How long has the program been managing the challenges/trying strategies?

* Child 2-Please describe other strategies you have tried to support this child's inclusion in the classroom. * Please upload a copy of the child’s plan (ex. , IEP, One Plan, 504, Treatment Plan) updated within the last six (6) months.

Please submit a screening or assessment if the child does not have a plan. * Browse Files Drag and drop files here Child 2-What services does the child receive?

* CIS Early Intervention / Developmental Education CIS Family Support Home Visiting CIS Early Childhood and Family Mental Health Consultation CIS - Home Visiting, Nursing Supports Early Childhood Special Education (formally EEE) School-Age Special Education Mental Health Services/Counseling Head Start/Early Head Start Children’s Personal Care Services Speech and Language therapy Occupational Therapy Deaf and Hard of Hearing support Vision Loss/Visual Impairment support Home Health Autism Consult Applied Behavior Analysis (ABA) Services Personal Care Assistance (PCA) UVM - Early Intervention Project of VT (formally the ITEAM) Other None Child 2-Does this child currently receive any direct supports at the child care program?

* Child 2-Please explain how often these services are provided at your program. * Child 2-Are there any barriers your program experiences to connecting or referring to service providers? * Child 2-What services or support has your program accessed to support this child/classroom?

* CIS Consultation and Education Seed and Sew training and/or coaching Early MTSS training and/or coaching Consultation from public school SPARQS coaching Other coaching, consultation, or specialized training Please upload the signed CIS Parent/Guardian Consent Form for child 3. * Browse Files Drag and drop files here JDO- Caledonia/S. Essex St.

Johnsbury ADO- Franklin/Grand Isle St. Albans HDO- Orange/N. Windsor- Hartford NDO- Orleans/N.

Essex- Newport SDO- S. Windsor/N. Windham Springfield Child 3 Application Status Approved-met scoring criteria Denied-did not meet scoring criteria Approved-then withdrew Incomplete could not score Application - Month - Day Year Date Picker Icon Child 3 Primary Physical Address * Child 3-Parent/Legal Guardian's Name * Child 3-Is the parent/legal guardian’s primary physical address different than the child’s?

* Child 3-Parent/Legal Guardian's Primary Physical Address * Child 3 - Parent/Legal Guardian's Email * Child 3 - Parent/Legal Guardian's Phone Number * Please enter a valid phone number. Child 3-Does the child/family receive Child Care Financial Assistance? * Child 3-Under what primary Child Care Financial Assistance Program (CCFAP) service need?

* Parent with special health needs Attending school or training Child with special health needs Child 3-Does this child/family have an open or custody case with the Family Services Division (FSD)? * Child 3-Has the child received a placement change within the last year (e.g., entering foster care, changing foster homes, or entering reunification)? * No, placement has remained stable for at least a year.

Yes, one placement change in the last year. Yes, two or more placement changes in the last year. Unknown Child 3-Family Services Worker's Name * Child 3-Family Services Worker Phone Number * Please enter a valid phone number.

Child 3-Family Services Worker Email * Child 3-Does the child/family have have insurance? * Medicaid Private Both Medicaid and Private Uninsured Child 3-Is this the child's first time in a child care setting? * Child 3-Has this child previously been required to leave a child care setting due to the program's inability to meet the child's needs?

* Child 3-Please explain. * Child 3-Is this child currently attending your program? * Yes No - Unable to access without additional supports.

Child 3-When did this child begin attending your program? * - Month - Day Year Date Picker Icon Child 3-Have the child’s needs (medical, behavioral, developmental, or personal care) affected their enrollment or participation in your program? (For example, requiring staffing changes, safety adjustments, or reduced hours/days.)

* No impact on enrollment Some adjustments have been made, but enrollment is stable Reduced hours Reduced days Reduced both hours and days Child is at risk of losing placement without additional support Child not able to attend childcare Staffing Ratio is at capacity Transitioning to a new classroom or group Other Child 3-What age group is the child transitioning to?

* Toddler Preschool School age FCCH mixed aged group Other mixed aged group Child 3-Please explain the barriers or challenges to having this child attend your program. * Child 3-Has this child been supported previously by SAG funding in your program?

* Child 3-Start Date of Last Grant Received * - Month - Day Year Date Picker Icon Child 3-End Date of Last Grant Received * - Month - Day Year Date Picker Icon Please enter the number of hours the child currently attends your program. All fields must