Dependent Care Voucher Program: Provider Enrollment

Dependent Care Provider Information

Please complete this form, and mail or hand carry to WORKlife Programs at The Johns Hopkins University, WORKlife Programs, 1101 East 33rd St., Suite C100, Baltimore, MD 21218.

Name of care provider / agency:

Street address: Apt ##:

City: State: Zip code:

Business phone: - -

License ## or Federal ID ## of care provider or agency:

Name of licensing organization:

Johns Hopkins employee name:

Please list each individual in this family for whom you are providing care and their birth date:

Note to Care Provider: We can only reimburse care for one (1) dependent per family.

Date care started: (mm/dd/yyyy) / /

This cost is: Weekly Monthly Hourly and is: Full-time Part-time

Do you receive additional childcare funds from the State of Maryland? Agency_________________ Amount__________

Care Provider:

1. The employee is solely responsible for contracting with you.
2. The Office of Work, Life and Engagement will call to confirm with you the child or adult's enrollment, your charges, and the employee's eligibility status for this program.
3. You will be required to provide a photocopy of your provider license to the Office of Work, Life and Engagement.
4. The Dependent Care Voucher Program will not reimburse employees at rates higher than are charged to other individuals in your care.
5. This financial assistance is only for dependent care costs for one (1) dependent. If you are caring for more than one dependent for this employee, you agree to determine the cost for one of those dependents and to record it monthly on the Monthly Cost Verification Form.
6. This financial assistance is only for work-related dependent care costs. Dependent care expenses accrued when employee is not working at the university must be paid by the parent and should be recorded separately.
7. You will be required to provide information regarding dependent care charges and employee payments. This office will provide the forms and it will be the employee's responsibility to bring them to you for completion.
8. 8. You will contact the Office of Work, Life and Engagement should the client begin to receive childcare funding from the State of Maryland.
9. Care providers who abuse this program will be reported to their appropriate licensing organization.
10. It will be the employee's responsibility to mail or hand carry completed original forms to the Office of Work, Life and Engagement, 1101 East 33rd St., Suite C100, Baltimore, MD 21218.

I have read and understand the above terms and conditions.

Care Provider Signature _____________________________________ Date ______________________

Employee Signature _____________________________________ Date ______________________