Homeless Certification

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					                              ATCAA Early Childhood Services
                                Head Start/State Preschool


                                       Homeless Certification


ATCAA General Child Care                                      ATCAA Head Start/State Preschool
935 S. State Highway 49                                       427 Highway 49 #305
Jackson, CA 95642                                             Sonora, CA 95370


To: _____________________________________________________________

Re: Parent’s Name: ________________________________________________


Certification: The parent listed above requires childcare services due to the
family being homeless and seeking permanent housing. If the parent has a
written plan for seeking permanent housing please attach a copy.


Name of Agency: __________________________________________________

Agency Phone # ____________________


Signature of representative: ___________________________ Date: __________




I hereby give my consent that an ATCAA Early Childhood Services Representative
may contact the above named agency to gather further information about my
plan in seeking permanent housing.


Signature of parent: ________________________________ Date: __________




C:\Docstoc\Working\pdf\c1c652b9-b65f-4c6c-b977-44ae6221e8ee.doc        7/10/08

				
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