Service Plan Application

Application

Please complete the following information for the specific program site applying for BWCWAR in this application (if you wish you apply for multiple sites, please complete a new application for each site)

Program Information

* Program Name:

* You must enter center name

Facility Number #:

Only Numbers allowed for Facility Number

* Program Type:
Please check all that apply

Arkansas Better Chance

Faith-Based

Family Child Care Home

Federal Subsidy (child care vouchers)

For-Profit

Head Start

Home Visiting

Hospital

Local Education Agency (school district or coop)

Non-Profit

University or College

* Please select program type

* Number of Staff:

* Required

* Number of Children Served (licensed capacity):

* Required

* Ages of Children Served:
Check all that apply

Under 12 months
12-24 months old
24-36 months old
3 to 5 years old

* Please select ages served

* Program County:

* Required

* Address:

* Required

* City:

* Required

State:

* Required

* Zip:

* Required

Primary Contact Information

* First Name:	* Required
* Last Name:	* Required
* Job Title:	* Required
* Email:	* Required *
* Direct Phone:	* Required
Alternate Phone:

* Are you currently enrolled in Better Beginnings?: * Required

Reason(s) for applying - tell us why you are interested in participating in the Be Well Care Well Arkansas program:

Selecting a Well-being Committee - Please Check Boxes to Confirm You Understand

* All checkboxes in this section are required


	Please begin considering the individuals who will be on your Well-being Committee. The expectation is that your committee members meet together with the Well-being Coach at least 4 times over the year, but as often as monthly. A crucial meeting is at the beginning of the project to select well-being goals. After the initial meeting the committee can decide how frequently it meets and when the meetings will take place during the workday. In order to receive BWCW services, the Director must agree to release Well-Being Committee members from their classroom responsibilities at agreed upon Well-Being Committee meeting times (typically 30 minutes)
	The role of the committee is to share ideas and develop strategies to help their program achieve their well-being goals. The Well-being Coach will communicate regularly with the committee to share opportunities and resources. The Well-being Coach will support your committee all along the way!
	Your committee can include as many individuals as you’d like and we ask that you have a minimum of three. When considering who you’d like on your well-being committee, think about individuals in your program who are already engaged in fitness, health or well-being actives. You’ll want an enthusiastic committee comprised of individuals who are fun, energetic and encouraging.
	We realize that everyone’s time is limited so rest assured that the work of this committee will not be overwhelming and everyone’s role can be adapted as needed to allow for participation.

Participation Agreement - Please Check Boxes to Confirm You Understand

To be Completed by the Director/Owner or an assignee.

* All checkboxes in this section are required


	Well-being Coach will visit monthly (or more) at agreed upon times
	I will participate as a member of my program’s Well-Being Committee.
	I will facilitate staff participation in well-being activities by providing release time away from classroom responsibilities during work hours as needed.
	A commitment to embracing well-being through fun and informative activities!

Type your name below to acknowledge you’ve read and agreed to ALL the Well-Being Committee descriptions and expectations listed in this application:

* You must print your name
* Director Name

* You must enter date
* Date

* I am ready to identify my Well-being Committee at this time

Yes

No

* Required

Please finalize your application by clicking the Submit Application button below.

Questions? Email us at susanna@curriculaconcepts.com