Contents
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Section 2 of 5 - Provider Information
As a result, the Legally Exempt Child Care Application: Section 2 of 5 - Provider Information page (LI0134) is displayed.
Complete the fields on this page as described below.
Last*, First* and Middle Names and Suffix
Enter the name of the applicant in the appropriate name fields.
Date of Birth*
Enter the date of birth using the following format MM/DD/YYYY.
Gender*
Select Female or Male by using the radio button next to the field ().
SSN (Social Security Number)*
Enter the Social Security Number for the applicant.
Home Address*
Enter the first line of the Home Address in this field.
Address Line 2
Enter the second line of the Home Address in this field.
City
Type the name of the city in this field. If the provider is located outside of Vermont, this is a required field.
State*
The State has been defaulted to Vermont; however if another selection is needed, select the name of the state by using the down arrow () next to the field.
Zip Code*
Enter the zip code in this field using the format #####-####.
Town of Residence
Select the name of the town by using the down arrow () next to the field. If the provider is located in Vermont, this is a required field.
Mailing Address
If the mailing address is different than the residence address, complete the field for the first line of the mailing address.
Address Line 2
If the mailing address is different than the residence address, complete the field for the second line of the Mailing Address.
City
If the mailing address is different than the residence address, complete the field for the name of the city.
Town
Select the name of the town by using the down arrow () next to the field.
State
If the mailing address is different than the residence address, complete the field for state. The State has been defaulted to Vermont; however if another selection is needed, select the name of the state by using the down arrow () next to the field.
Zip Code
If the mailing address is different than the residence address, complete the field for the zip code using the format #####-####.
Contact Phone*
Enter the main telephone number in this field using the format ###-###-####.
Alternate Contact Phone
Enter the alternate telephone number in this field using the format ###-###-####.
Related to Child(ren)*
Select Yes or No by using the radio button next to the field () to indicate if the potential LECC provider is related to the child or children for whom care is being given.
If Yes, Indicate Relationship
If the answer to the above question is Yes, select the relationship by using the down arrow () next to the field.
Aunt/Uncle
Grand/Great Grandparent
Sibling
Currently a Foster Parent*
Select Yes or No by using the radio button next to the field () to indicate if the potential LECC provider is currently a foster parent.
Currently Providing Respite Care*
Select Yes or No by using the radio button next to the field () to indicate if the potential LECC provider is currently providing respite care.
Applicant resides in the home of the eligible family*
Select Yes or No by using the radio button next to the field () to indicate if the potential LECC provider is currently residing in the child's home.
More:
Education Status (Required if applicant is 16 or 17)
Parent Statement of Understanding