APPLICATION

Applicant Name: ____________________________________________

Address: ___________________________________________________

City/State/Zip: ______________________________________________

Phone: ____________________________________________________

E-mail: ____________________________________________________

Contact Person: _____________________________________________

Phone: ____________________________________________________

Requested Amount: $___________________

Business Partner Information

Business Partner: __________________________________________

Address: ___________________________________________________

City/State/Zip: ______________________________________________

Phone: ____________________________________________________

E-mail: ____________________________________________________

Contact Person: _____________________________________________

Phone: ____________________________________________________

(if there is more than one business partner include the business partner information for each business partner)

Amount being invested: $___________________

1 2000 Days Grant Application –Form to complete

This application is available on the website:

www.scottcountykids.org

1) Copy of the DHS center license or DHS child development home registration certificate. (must be attached)

2) State the ages of children being cared for at the center or home. __________________________________________________________

3) What quality initiative(s) will you achieve or maintain? __________________________________________________________3a) Will this/these quality initiative(s) be achieved (for the first time) or maintained? ________________________________________________

4) A brief narrative on how the quality equipment request will assist in maintaining or achieving quality standards. (maximum 500 words) (attach page or download application from website and enlarge area to meet your needs)

5) Identify specific equipment and itemized costs of materials to be purchased with grant funds. (attach page or download application from website and enlarge area to meet your needs)

6) Please state timeline on ordering, purchase date, and installation if needed. Reminder: by June 15, 2012 (or prior):

All materials must be delivered and installed (if applicable) at the child care home or center

Documentation of purchase (receipts, shipping slips) must be received at the Scott County Kids Early Childhood Iowa office so that you may be reimbursed (only materials approved and identified in a valid contract will be eligible for reimbursement).

Date Task

2 2000 Days Grant Application –Form to complete

7) A brief discussion on how you educated, informed and engaged your business partner. (attach page or download application from website and enlarge area to meet your needs)

8) Written documentation from business partner(s) verifying: financial commitment to this project brief discussion of what they learned about early education and early care

providers, maximum of 250 words. (must be attached).

9) Identify strategies on how you will promote and inform business stakeholders and the community at large on your specific Project 2000 Days plan. (attach page or download application from website and enlarge area to meet your needs)

10) Copy of the quality initiative application that will be sent to accrediting/awarding agency. Example: a copy of the Quality Rating System application that will be sent to DHS.When will this application be submitted to accrediting/awarding agency? ____________________________________________(must be attached)

3 2000 Days Grant Application –Form to complete