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* 1. Organization Name

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* 2. Contact Person and Title

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* 3. E-mail address

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* 4. Organization Address

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* 5. Phone Number

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* 6. Hours of Operation

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* 7. Website address

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* 8. Please upload a copy of your current rate/fee schedule.

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* 9. Please describe the services your organization offers.

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* 10. Please describe your organization's experience providing these services.

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* 11. Please list the minimum qualifications for your full-time and part-time staff.

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* 12. Please describe how you monitor the effectiveness of services provided.

Please initial the following items to confirm your organization and employees will comply with the program requirements and rules as established by Act 234 of 2023 (known as the LEARNS Act) and rules promulgated by the Arkansas State Board of Education.

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* 13. I understand that all student-facing employees must have a background check on file. Proof of background checks must be furnished upon request to the Arkansas Department of Education (ADE).

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* 14. I understand that all services provided by student-facing employees of this organization are subject to ADE review and approval. All employees must display their credentials for the services to be provided.

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* 15. I understand that all services provided by student-facing employees of this organization are subject to continuous review by ADE to maintain this organization's eligibility to remain a participant in the Education Freedom Account program. Program rules are subject to change with reasonable notice.

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* 16. I understand that all services provided by student-facing employees of this organization are required to meet or exceed the eligibility criteria outlined in the Education Freedom Account rules and are subject to continuous review by ADE.

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* 17. I understand that all services provided by student-facing employees of this organization will comply with all applicable state and federal health and safety laws, rules, and regulations.

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* 18. Please type your full name below to record your signature.

Please ensure all required documentation is submitted with the completed application. Incomplete applications and those submitted without required documentation will be returned to the applicant.

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