Child Care Application

Document Sample
Child Care Application Powered By Docstoc
					                               Bristol Bay Native Association
                               Workforce Development Center
                                   Child Care Program
                                             P.O. Box 310
                                      Dillingham, Alaska 99576
                     Phone 842-4059 or Toll Free 1-800-478-4059 Fax 842-1539

Dear Parent or Guardian:

We are pleased that you are interested in applying for Child Care Assistance and hope we are
able to help. To get your application file in order and establish your eligibility, please do the
following:

If you received Tribal TANF or have received it in the last 6 months you are not eligible for
BBNA’s Child Care assistance. If you are currently receiving Tribal TANF contact your case
manager for child care assistance. If you have received Tribal TANF in the last 6 months
please call your case manager at 1-888-265-2262.

1.    Fill out the attached application completely.

2.    Submit a completed Child Care Provider Registration Form (enclosed).

3.    Submit ALL copies or proof of income with your application. The previous year’s taxes
      and W-2’s and last pay stubs for current year and itemized fishing statements.

4.    Submit proof that your children are Alaskan Native or Indian descendants (copy of
      children's Tribal cards or copies of the children's birth certificates and copy of parent’s
      Tribal card)

5.    Everyone in the home over 18 years old needs to sign an Authorization for release of
      information form.

6.    Submit a copy of your all your child/ren's Immunization records.

PLEASE NOTE:

1.    BBNA has 30 days to determent eligibility for your case.
2.    You are responsible for all of your child care expenses unless otherwise notified by
      BBNA.
3.    We cannot determine eligibility, until we have all the required paperwork and completed
      application forms.
4.    A completed child care application does not automatically mean a client is eligible for
      child care assistance.
5.    Child Care is approved from the date we receive ALL the necessary documents to
      determine your case. No child care is approved before that date.
                                                1
                                             Child Care Assistance

   The Child Care Development Fund serves individuals and families by increasing the availability,
   affordability, and quality of child care in the BBNA service area.

APPLICATION:

Client must apply for services using the Child Care Assistance Application Form.

Client must choose their child care provider.

        A.      The child care provider can be a relative, friend, licensed daycare home.

        B.      If the client chooses a family daycare home (home that is not licensed, but can be a relative or
                friend) they must register with BBNA using the Child Care Provider Registration Form. The
                provider must be 18 or older and cannot reside in the home with the children or the client.

        C.     A licensed daycare home must provide a copy of their license for the file.

        D.      If there is someone living in the home 18 or older, is not working, in training or in school,
              and is capable of caring for the children then child care cannot assist.

ELIGIBILITY:

A client’s eligibility is based on the following criteria:

        A.      Parent(s) must be involved in one of the following activities: working, training/education or
                subsistence activities.

        B.      Children must be Native Descendents. (Proof can be CDIB’s, Copy of parents’CIDB’s with
                copy of children’s birth certificates.)

        C.      Parent(s) past 12 months income must not exceed income guidelines.

INCOME:

Eligibility is determined by using the client’s previous 12 month income OR projecting the client’s current
income.

        A.      Past Net Income will be used.

        B.     Projected net Income will be used.

   If you have any questions or need additional information please call our toll-free number
   at 1-800-478-4059.



                                                        2
                                             Bristol Bay Native Association
                                              Workforce Development Center

                                                  Central Intake Form

Name                                            SSN:                              DOB:
       Last           First           M.I.
Physical Address:                               Phone:                       Email:                     Female
                                                                                                          OR
Mailing Address:                                Primary Language:                                        Male
City, State, Zip:                                                Veteran:        Yes         No
Are you disabled? If so, briefly describe your disability and when it started.


Marital Status:      Single    Married         Widowed           Divorced        Separated        Living together
                                                                                                   As a couple
Which Village are you Tribally Enrolled With?
Which Village do you Physically Live in?
Ethnicity:        AK Native        Native American           Native Hawaiian             Non-Native (Caucasian)
List ALL household members, for additional members, use back of this page:
LAST NAME                      FIRST NAME              MI               Relationship               DOB/SSN




                                       List All Household Income
Person Receiving Income                        Amount                 Source (paycheck, unemployment, etc.)




Circle One:       HS Diploma     GED           If neither, what is the highest grade completed?
List your Education and the Years Attended:
High School:
College/Technical Training:
Additional Certificates or Classes:
Do you have a current Alaska Driver’s License?         Yes            No               Expiration Date:


                                                             3
List your Work History: (begin with most current)
Employer Name               Address/Phone          Supervisor        Duties/Title    Hourly Wage             Begin/End Date




Please check all Barriers that apply to you:
        Single Parent/Head of Household                                       Currently Employed/Low Income
        Limited English Proficiency                                           Not in Labor Force
        Disabled or Household Member Disability                               HS Dropout/No GED
        Offender                                                              Long-Term TANF Recipient
        Reading Skills below 7th Grade Level                                  Lacks Significant Work History
        Math Skills below 7th Grade Level                                     Homelessness
        Public Assistance/Food Stamps/GA                                      Substance Abuse Issue
        Tribal TANF Recipient                                                 Pregnant or Parenting Teen
        Unemployment                                                          Never had a Driver’s License
        Unemployment 15+ Weeks                                                Do not have an Alaska Driver’s License
        Lack of Child Care                                                    Other
                                                                              Other
Please List your Skills:
        Computer Skills, List software you know and your WPM

        CDL/HEO                                                      Other
        HazMat Certificate                                           Other
        CPR First Aid                                                Other
        10-Key calculator                                            Other
        Can operate Multi-line phone                                 Other
        Operate Fax Machine                                          Other
        Operate Copy Machine                                         Other
        Mechanic                                                     Other
        Carpentry                                                    Other
        Laborer                                                      Other
        Plumbing or Electricity                                      Other
        Beading/Skin Sewing                                          Other

List any additional information not already listed pertinent to your needs:




For Office Use Only:

       Staff ID Initials:          Date Entered:              Assigned CIF #              Referrals:




                                                                 4
Place a check mark next to the services you are requesting and include this intake form with a proper application.

       Child Care Assistance                 Supportive Services                   CDL Training

       General Assistance                    Job Readiness Training                Heavy Equipment Training

       Job Search                            Specialized Training                  Hazardous Material Refresher

       Resume Assistance                     Higher Education                      Alaska Driver’s License

       Burial Assistance                     Adult Vocational Training             Building Maintenance Repair

       Interview Skills                      Typing Test

       Other: Please Specify




                                                           5
                                       Request for Child Care

     I am requesting        hours of child care per day,                  days a week for the following children in
     my household, who are under age 13:

         1.                       .        3.                        .     5.                                 .


         2.                       .        4.                        .     6.                                 .



     I am in need of child care assistance because:

              I currently work         hours per day,            days a week.

              Place of Employment                                    Phone #                                      .

              I am attending training from          /       /       to         /         /        .

              I am enrolled in school at                                                                      .

              I or my spouse engages in subsistence activities                     f/t          p/t to help
              Support my family.

              My spouse works               hours a day             days per week

              Place of Employment                                                  Phone #                        .




Applicant’s Signature                       Witness Signature (if “X”)                   Date


EMERGENCY CONTACT                                                        Phone #

     Comments:




                                                        6
                                                  Bristol Bay Native Association
                                                 Workforce Development Center
                                                            P.O. Box 310
                                                       Dillingham, AK 99576
                                      Toll free: 1-800-478- 4059 or Local: 907-842-4059
                                                         Fax: 907-842-1539


                                           Authorization for Release of Information


I hereby authorize the release of all information needed by BBNA Workforce Development Center contained in the
City Councils, Village Councils, State, and Federal, Private or Educational Agencies’ records to the organization
listed above:




This information is needed for verification of eligibility for:



PRINT FULL NAME
This authority shall continue in effect until this client is no longer of BBNA’s Workforce Development Center’s Services.


Furthermore, that authorization is being given to the BBNA Workforce Development Center to proceed on my behalf to provide
employment assistance services included (but not limited to):


            1.     Referral to potential employers
            2.     Inclusion in a Talent Bank/Skills Survey



Social Security Number                                                 Date of Birth



Signature                                                              Date




                                                                  7
                                                 Bristol Bay Native Association
                                                Workforce Development Center
                                                          P.O. Box 310
                                                     Dillingham, AK 99576
                                       Toll free: 1800-478-4059 or Local: 907-842-4059
                                                       Fax: 907-842-1539



                                                Photo Release of Authorization Form




I                                                             hereby consent, without further consideration or compensation, to the use
(full or in part) of all photographs, digital photos or any video taping made of me during WFD/Training events and/or activities, by
BBNA or the employer I will be working with. For the purposes of internet web productions to the web site www.bbna.com or any
monthly reports, newsletter, annual reports. Further, I release BBNA or any employment and/or training agency and their members
from any liability which may arise from the use of those materials.




I                                                          DO NOT want photos of myself or my family published to the district
website or any of the following listed above.




This Release will remain in full force and effect until withdrawn in writing by me.

Name:

Community:

Position:

Signature:

Date:




                                                                8
                                           NOTIFICATION TO CLIENT


The Federal law concerning fraud states… “Whoever in any matter within the jurisdiction of any department or
agency of the United States, knowingly and willingly falsifies, conceals or covers up by any trick, scheme or device a
material fact, or makes any false fictitious or fraudulent statements or representations or makes or uses any false
writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry shall be fined
not more than $10,000.00 or imprisoned not more than five years or both.”


Under the Privacy Act. 5 U.S.C. 552 (a) (1) (2), Workforce Development cannot give out information you give the
caseworker except Workforce Development can share this information with other Federal, State, Tribal offices and
programs who have some responsibility with the Workforce Development Center for which you are applying. The
information can also be given to those agencies when you ask them for a job or for some other benefit and for law
enforcement purposes. This can be done without your written consent. For any other person or program wanting
information is in your case record and you can ask to see it. If you believe some information is inaccurate, ask your
caseworker about how to change the information in the case record.


This must be read and signed



Printed Name of Client



Client’s Signature




                                                          9
                      **IMPORTANT NOTICE ABOUT YOUR RIGHTS**

                                                    FAIR HEARING
Any person whose application is denied or not acted upon within 30 days, or whose benefits are reduced or terminated,
has a right to a hearing before the Bristol Bay Native Association.

If you desire a hearing, you may request it by telephone, in person, or in writing through the Child Care Development
Block Grant Program, P.O. Box 310 Dillingham, Alaska 99576. You must make your request within thirty (30) days
after you receive notice of a decision on your Child Care Assistance case.

B.B.N.A. is available to assist you if you request a hearing. At the hearing you may represent yourself. You may also be
represented by legal counsel (e.g. – Alaska Legal Services Corporation or by another person of you choice (e.g. –friend
or relative.))

                                                    CIVIL RIGHTS
The Civil Rights Act of 1974 states “No person in the United States, on the ground of race, color, or national origin,
shall be excluded from participation or be denied the benefits of federal assistance.” If you feel you have been
discriminated against, you may file a complaint with the Bristol Bay Native Association or with the United States
Department of Health and Human Services.

                                                   PARENTAL CHOICES
If your application is approved, you will have complete and total authority to select the type of child care you prefer and
any specific child care provider, as long as the child care provider you identify meets the registration and/or State or
Tribal licensing criteria, and is willing to enter into agreement with the Bristol Bay Native Association Child Care
Development Block Grant Program to serve as a vendor. (Copies of the child care provider registration and the tribal
licensing forms for the program can be obtained by contacting the C.C. and D.B.C. Coordinator at B.B.N.A. Social
Services Department.)

                                                     AGREEMENT
If your household receives assistance, you must agree to the statement below. Any member of you household who
deliberately breaks any rules and receives benefits to which they are not entitled to will be required to pay back the
benefits received under false information and may be prosecuted.

        I certify that I have checked the information on the application carefully and it is true and complete of the
       facts according to the best of my knowledge and belief.
        I understand that it is against the law to make false statements and that I am subject to prosecution if I do.
        I understand that a B.B.N.A. representative may call my home, and may contact other people in order to verify
my eligibility for assistance. I also understand that information I give may be verified by computer        cross-
matching with other agencies.
        I authorize the Alaska Department of Labor to release to the Bristol Bay Native Association, information
       about my eligibility for unemployment insurance and work credits.
        I authorize the Bristol Bay Native Association to communicate with my child care provider and other agencies
       on my behalf, as it relates to the Child Care Development Block Grant Program.
        I understand that my household can submit only one application for Child Care Assistance per year.
       Furthermore, I certify that this is the only application submitted from or on behalf of my household.

                                                                                            /       /
Applicant Signature                           Witness Signature (if “X”)             Date

                                                          10
                                  Bristol Bay Native Association
                                  Workforce Development Center
                                      Child Care Program
                                                 P.O. Box 310
                                          Dillingham, Alaska 99576
                      Phone 842-4059 or Toll Free 1-800-478-4059 Fax 842-1539

Dear Provider:

We are pleased that you are interested in applying to be an approved Child Care Provider
and hope we are able to help. To get your application file in order and establish your
eligibility, please do the following:

1.       Fill out the attached Child Care Provider RegistrationForm completely.

2.    Submit Interested Persons Report (Criminal Background Check) for all members of
the household whom are 16 years of age and older. This can be obtained through the State
Troopers office. * If you are providing care in the clients home you only need to submit a
report for yourself.

3.       Submit current TB test Results.

4.       Submit a copy of your Social Security Card along with the attached W-9 Form

5.       Submit a copy of your business license application and payment prior to mailing off
         to the State of Alaska.


PLEASE NOTE:

1.       BBNA has 30 days to determent eligibility for your case.

2.       Child Care is approved from the date we receive ALL the necessary documents to
         determine your approval. Payments will not be paid before approval date.

3.     The provider must be 18 or older and cannot reside in the home with the children or
the client.




     If you have any questions or need additional information please call our toll-free number at 1-800-
     478-4059 ext. 405 or 410.

                                                   11
                              CHILD CARE PROVIDER REGISTRATION
                                    Bristol Bay Native Association
                                   Workforce Development Center
                                             P.O. Box 310
                                        Dillingham, AK 99576
                                  (907) 842-4059 or 1800-478-4059
                                            Fax: 842-1539


Each person or agency who provides child care for a parent or guardian receiving child care assistance from
the Bristol Bay Native Association’s Child Care Development Fund must complete this form and be approved
before child care payment can be authorized.


THE BRISTOL BAY NATIVE ASSOCIATION RESERVES THE RIGHT TO DENY REGISTRATION
AND PAYMENT TO ANY PERSON OR AGENCY WHO IS DETERMINED BY THE TRIBE TO BE A
POTENTIAL DANGER TO CHILDREN BECAUSE OF CURRENT OR PAST ASSOCIATION WITH OR
PARTICIPATION IN CRIMINAL ACTIVITIES, ALCOHOL OR OTHER SUBSTANCE ABUSE,
COMMUNICABLE HEALTH PROBLEMS, OR UNSAFE CHILD CARE PRACTICES.


Please read page 2 questions 1-3 these are the NEW REQUIREMENTS FOR ALL CHILD
CARE PROVIDERS.


* If the child care provider plans to care for more than four children unrelated to him or her, it is
necessary that the provider be licensed by the State of Alaska, you can reach them at (907)269-4783.
If the provider plans to care for more than four children in his/her home, he/she must be licensed
By the State of Alaska before BBNA will authorize payment for child care. These caregivers must also
be in compliance with any tribal licensing currently in effect.



*
     Name of Parent (Client)
For whom you will provide child care



Address or P.O. Box



City/Village, State, and Zip Code



                                                    12
                           INFORMATION ABOUT THE CHILD CARE PROVIDER


     Name of Provider                          Date of Birth                      Social Security #


     Mailing Address                           City/Village & Zip                        Phone #

                                      OTHER HOUSEHOLD MEMBERS
     Name                    Birthdate         Relationship to Social Security #
                                               head
     1.
     2.
     3.
     4.
     5.
     6.

1.        Business License. All Providers must submit a current State Business License. I will need a copy
          of your completed Business License application and your check or money order for your file.
          When you receive your license I will need a copy of that also. The amount of the State Business
          License is $200.00 for 2 years or $100.00 for 1 year.

The following is now required to be submitted with the Application:

2.        Criminal Background checks are REQUIRED for everyone in the home 16 years old and over
          If you are providing care in your home, only for the provider if care is in parents home. IF
          CRIMINAL BACKGROUND CHECK COMES BACK AND THERE ARE CRIMES OF
          VIOLENCE OR ANY KIND OF ASSAULT, YOU WILL NOT BE AN APPROVED CHILD
          CARE PROVIDER. You need to see the State Trooper or the VPSO to obtain one. The cost is
          $20.00 per person. CRIMINAL BACKGROUND checks are Mandatory!

3.        A Current TB test. Please send us the results of the test for our records. If you have had TB, I will
          need a letter from your doctor. ALSO A COPY OF YOUR SOCIAL SECURITY CARD

4.        How are you related to the child?

5.        How many children do you plan to provide day care?

6.        What ages of children are you willing to serve?

7.        What hours are you willing to provide care?

8.        What days are you willing to provide care?
9.        Where is care provided?              In My Home                  In a Center
                                                            13
                           CHILD CARE HEALTH/SAFETY CHECKLIST
                        (TO BE COMPLETED BY PARENT AND PROVIDER)


PROVIDER

YES         NO

1.                  Are you 18 years of age or older?

2.                 Does anyone in the Household have a criminal record?

3.                 Has everyone in the home 16 years old and over obtained a Criminal Background check?

4.                 Do you fully understand that you are required by law to report suspected child abuse?

5.                 Do you provide a smoke, drug and alcohol-free environment for the children in your care:
                   this includes your child care site and vehicle used to transport children?

6.                 Does each floor of home have at least one properly installed and maintained smoke detector?

7.                 Do you have a fire extinguisher, which is readily accessible and maintained in operable condition?

8.                 Do you have a first aid kit that is in a convenient location and is inaccessible to children?

9.                 Ventilation, temperature, and lighting are adequate for children’s safety and comfort.

10.                Are poisons, toxic materials, cleaning substances, sharp or pointed objects, and guns kept in a safe
           place or locked up so the children cannot get to them?

11.                Is there a safe play area provided, including inside and outside areas?

12.                Are the floors and walls clean and maintained in a condition safe for children?

13 a.              Does the child care provider have a plan to evacuate children in the event of a fire?
13 b.              And is it posted on the wall for the Parents to see when they drop off their child?

14.                Are there at least two ways of exiting the location where child care will be provided?

15.                Are toys and objects (i.e. high chair) are safe, durable, easy to clean, and non-toxic?

16.                Do you use any physical punishment (i.e. spanking or hitting), or any form of verbal abuse (i.e.
                   Name calling), which may hurt the child emotionally?

17.                Are you aware of each child’s location at all times and will protect the child from danger.

18.                Are you able to prevent exposure of children to high-risk situations, including exposure to physical
                   hazards and encounter with individuals or animals posing a possible danger?



                                                         14
                                                 CHILD’S HEALTH

YES           NO

19.                         Do you provide daily activities to promote a child’s individual physical, social, intellectual,
                            and emotional development that includes time for sleep, toileting, indoor, and outdoor play
                            and exercise according to individual needs?

20.                         Do you provide sufficient nutrition so that: a. A child is fed nutritious meals and snacks
                            according to individual needs; b. an infant is fed on demand; c. Except for medical reasons,
                            a child is not denied a meal or snack, force fed or otherwise coerced to eat against the
                            child’s will.

21.                         All medicine, prescribed and/or over-the-counter, will be administered only with written
                            parental instruction?

22.                         Do you use a separate towel and/or washcloth on the children?

23.                         Do you do diaper changing and toileting, away from the food preparation area?

24.                         Do you keep emergency information on each child and contact the child’s parent in case of
                            illness or injury?

25.                         Do you provide the parent access to their child whenever their child is in your care?

26.                         Do you have a ample supply of safe, drinkable water in your child care home?

PARENT

As the parent whose child (ren) will be provided child care from the person signing below, I certify that I have
answered all of the questions honestly and to the best of my knowledge.


PROVIDER

I certify that I will comply with all the requirements set forth by the Bristol Bay Native Association Child Care
Development Fund Program, governing the registration of child care providers and that my answers to all the questions
and statements I have made on the pages of this registration are true and correct to the best of my knowledge.



      Signature: Parent of Child (ren)                                            Date


      Signature: Child Care Provider                                              Date


                                                              15
         Qualifications of Persons Having Regular Contact with Children in a Child Care Facility

               As per 4 AAC 62.210(b) and (d) as referenced in 4 ACC 65.185(a)(3): Approved Providers

An individual may not work, volunteer, or reside in a child care facility or in any other part of the premises housing a
child care facility, if the individual has the opportunity to access to the child care facility and:

     Is the alleged perpetrator of an incident of child abuse or neglect in which the department of Health and Social
      Services found the evidence available substantiates the allegation, or the information available to the department
      demonstrates to the department the individual’s inability to adequately provide care and supervision to children:

     Has a physical, health, mental health or behavioral problem to an extent that the problem poses a significant risk to
      the health, safety, or well-being of children in care:

     Has a domestic violence or alcohol or other substance abuse problem to an extent that the problem poses a
      significant risk to the health, safety or well-being of children in care:

     Was the subject of prior adverse licensing action:

     Was, within the last 10 years, under indictment, charged by information or complaint, or convicted of any of the
      following misdemeanor offenses:

              *       Assault
              *       Reckless endangerment
              *       Misconduct involving a controlled substance
              *       Perjury

     Was, at any time, under indictment, charged by information or complaint, or convicted of any of the following
      offenses:
             *       An offense against the family and vulnerable adults
             *       Perjury under AS 11.56.200
             *       A serious offense

     For a list of offenses please request a copy from the Child Care Coordinator.




 I have read and understand the above statement.




 Signature                                                                 Date




                                                               16
                                                   Bristol Bay Native Association
                                                  Child Care Provider Reference

This is a reference for                                       which I have known for                           in the capacity of
                                 Child Care Provider’s Name                                          Year, Months



(Friend, Co-worker, Employer, etc.)        Not a Relative


I know this person: Very                 Well   Casually            Not well                  enough to give   a reference

Please answer the following questions:
  1. Does this provider show any serious health, alcohol or drug problems?                     Yes                NO
    If yes, please explain:


  2. Can you attest to the good character, maturity and sound judgment of this provider? Yes                                 No
     If no please explain:


  3. How would you assess the Providers ability to provide good care to children?

    Check one:               Excellent                     Good                        Fair                                  Poor

  4. List those qualities, which you believe will enable the provider to work successfully (or unsuccessfully)




  5. If you needed a Child Care Provider, how would you feel about leaving your children with this Provider?

             Very enthusiastic                  somewhat enthusiastic              Worried                        Would NOT



  Comments:




  Print Name of Reference                  Signature of Reference                       Date                           Telephone Number


  Address of Reference                              City                       State                           Zip Code


                                                                         17
                                                   Bristol Bay Native Association
                                                  Child Care Provider Reference

This is a reference for                                       which I have known for                           in the capacity of
                                 Child Care Provider’s Name                                          Year, Months



(Friend, Co-worker, Employer, etc.)        Not a Relative


I know this person: Very                 Well   Casually            Not well                  enough to give   a reference

Please answer the following questions:
  1. Does this provider show any serious health, alcohol or drug problems?                     Yes                NO
    If yes, please explain:


  2. Can you attest to the good character, maturity and sound judgment of this provider? Yes                                 No
     If no please explain:


  5. How would you assess the Providers ability to provide good care to children?

    Check one:               Excellent                     Good                        Fair                                  Poor

  6. List those qualities, which you believe will enable the provider to work successfully (or unsuccessfully)




  5. If you needed a Child Care Provider, how would you feel about leaving your children with this Provider?

             Very enthusiastic                  somewhat enthusiastic              Worried                        Would NOT



  Comments:




  Print Name of Reference                  Signature of Reference                       Date                           Telephone Number


  Address of Reference                              City                       State                           Zip Code


                                                                         18
                                  Notification to Child Care Provider


The Federal law concerning fraud state… “Whoever, in any matter within the jurisdiction of any department or
agency of the United Stated, knowingly and willingly falsifies, conceals or covers up by any trick, scheme or device
a material fact, or makes any false fictitious or fraudulent statements or representations or makes or uses any false
writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry shall be
fined not more than $10,000.00 or imprisoned not more than five years or both.”


Under the Privacy Act 5 U.S.C. 552 (a) (1) (2), Workforce Development cannot give out the information you give
the caseworker except Workforce Development can share this information with other Federal, State, Tribal offices
and programs who have some responsibility with the Workforce Development for which you are applying. The
information can also be given to those agencies when you ask them for a job or for some other benefit and for law
enforcement purposes. This can be done without your written consent. For any other person or program wanting
information is in your case record and you can change the information in the case record.


This must be read and signed



Child Care Provider’s Signature




Printed Name of Child Care Provider




                                                            19
20
21
22

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:9
posted:5/6/2012
language:English
pages:22