Community Rates Application | BSC Providers LLC

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Community & Roots Rates Application

Please complete the application below so our team can review your eligibility and determine which rate option may best fit your needs.

One application is used for both Community and Roots Rates.

Parent/Guardian Information

Parent Name (First & Last)*

Email*

Phone

Childcare Information

Children Name & Ages

What type of care are you looking for?*

If you are requesting consistent weekly care, what days and times do you need? Example: Monday, Wednesday, and Friday from 3:00–6:00 PM

Eligibility

Do you qualify for any of the following? Check all that apply. *

SNAP

Medicaid/LaCHIP

WIC

Section 8 Housing Assistance

Free or Reduced-Price School Lunch

Household Income Under 200% of the Federal Poverty Level

Single Parent or Financial Hardship

How would receiving a reduced childcare rate help your family?*

Rate & Service Agreement

Please confirm that you understand the following:*

I understand that Community Rates are intended for flexible or occasional childcare needs.

I understand that Roots Rates are intended for consistent weekly childcare and require a commitment of at least 8 hours per week for a minimum of 4 weeks.

I understand that a 3-hour minimum booking applies.

I understand that reduced-rate availability is limited and subject to BSC's 20% program capacity cap.

I understand that submitting this form does not guarantee eligibility, availability, or placement at a reduced rate. 

I have read and agree to the terms above. *Required * I agree

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