Provider Wage Supplement Center Application

About Your Facility Building
Address*
Street Address City ZIP Code
The building your are using for child care is:
- Leased by an individual
- Leased by our child care business or LLC
- Has a mortgage
- Is owned outright (no mortgage)
What date did your center begin operating at its current location?*
How many child care educators does your center require to be fully operational?*

About The Children You Serve
Enrollment Capacity:
What ages of children do you serve?*
(check all that apply)
- 0-17 Months
- 18-35 Months
- 3-5 Years
- 6-12 Years
When fully staffed, what is the total capacity of children you are able to serve?
Ages 0-3*
Ages 4-5*
Current Enrollment:
How many children do you currently have enrolled in your center?
Ages 0-3*
Ages 4-5*
Total Number of Children*
Number of CCMS Children*

Summary

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05/23/2022
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Data Sharing Agreement*
By participating in the wage supplement program, your agency’s Employer Identification Number (EIN) and select wage supplement application information will be shared with Texas Policy Lab as part of a study, in partnership with Workforce Solutions for Tarrant County and Child Care Associates, to evaluate the impact of the wage supplement program in child care staff retention and turnover. Your agency’s participation in the program will help TPL evaluate the impact, suggest changes and make recommendations to strengthen the efforts to improve retention and curb turnover. Any results from the study will be shared in a report at the aggregate level and will not include any direct or indirect identification of individuals or agencies.
- Please check this box to acknowledge that you understand the above statement.
By signing this document, you agree to the following statement:*
I certify that all information provided on this form is true and accurate. I understand that giving false information may constitute fraud and could result in prosecution.
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Basic Information