Childcare for Voters Certification Form

Childcare for Voters Certification Form

This form is to be submitted AFTER care has been provided, within 2 weeks of the final day of care, and must be signed to receive reimbursement. Submissions that are not returned within 14 days of the election may not be fully reimbursed.
I certify that child care was provided at by the organization on Election Day as promised and agreed upon in the childcare funding request form and any other associated emails or documents for the purpose of supporting parents casting their vote in the election, which includes any early voting dates.
Name*

First NameLast Name
Organization / Company name*
Where childcare was provided
Number of families who used the service
Total number, if known
Number of children cared for*
Total number
Total cost of the childcare provided for voters (reimbursement amount):*
Dollar amount to be reimbursed
Preferred payment method:*

CheckZelle transfer
Address (to send check):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email or phone number for Zelle transfer:
email or phone number associated with your Zelle account
On a scale of 1 to 5, how effective did you find the Childcare for Voters program in supporting caregivers during elections?*

1 Very Dissatisfied - The program/provider experience did not meet expectations at all.2 Dissatisfied - The program/provider experience fell short of expectations in several areas.3 Neutral - The program/provider experience was neither particularly positive nor negative.4 Satisfied - The program/provider experience generally met expectations with minor issues.5 Very Satisfied - The program/provider experience exceeded expectations significantly.
How would you rate the ease of coordination and communication with Politisit on a scale of 1 to 5?*

1 Very Dissatisfied - The program/provider experience did not meet expectations at all.2 Dissatisfied - The program/provider experience fell short of expectations in several areas.3 Neutral - The program/provider experience was neither particularly positive nor negative.4 Satisfied - The program/provider experience generally met expectations with minor issues.5 Very Satisfied - The program/provider experience exceeded expectations significantly.
What specific benefits have you observed for the families using the childcare services?*
Any stories or information you can provide will help us continue this program.
How could Politisit improve to better support your role as a provider?*
Please list any challenges you faced partnering with us or any suggestions we can use to improve for the future. If you don't have any thoughts now, you're welcome to write N/A and email us later if something comes to mind.
Would you recommend partnering with Politisit to other providers?*

YesNo
Best email for us to contact you if we have questions:*
example@example.com
Declaration

I declare under penalty of perjury that all the information provided on this form is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement in this electronic form, or causes someone else to do so, commits a crime and may be subject to penalties under Federal and/or state law. By signing, I declare that everything in this form is true to the best of my knowledge.
Signature to certify all the above information is accurate. *

Clear
Title if signing on behalf of an organization.
Should be Empty:

Childcare for Voters Certification Form

Declaration