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* 1. Are you a contracted School Readiness provider with an active contract for 2019-2020

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* 2. Name (person completing this application)

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* 3. Name (company)

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* 4. Address

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Email Address

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* 9. Phone number

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* 10. Describe the supplies, materials or services you have purchased for your program to aid in the mitigation of the COVID-19 virus.

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* 11. Is your School Readiness program currently open for business?

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* 12. If you are not open for business, when do you anticipate opening?

Date

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* 13. Is there anything else you would like for us to know about your School Readiness program that would help your program recover from COVID-19?

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* 14. Upload your receipts of purchase showing Health and Safety supplies, materials or services that you are submitting receipts for up to $500.

A. Receipts must be dated after March 1, 2020
B. Bank statements will not be accepted as proof of purchase.
C. If turning in receipts for cleaning service, receipts must have the business name on them, the date the work was completed, and the receipt marked as paid by the business.

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