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Confirmation of Child Care Provider Form

This form is used to confirm the child care provider chosen for taking care of your child(ren). The provider completes and signs the form to help complete the voucher. Use one form per provider if you're using multiple providers.

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How do I fill this out?

To fill out this form, follow the instructions provided in each section carefully. Ensure all required fields are filled in accurately. Double-check the information before submitting to avoid any delays.

How to fill out the Confirmation of Child Care Provider Form?

1
Obtain the form and have your chosen child care provider complete and sign it.
2
Fill in the parent's name, contact number, and child's details.
3
Indicate the program type for each child using the provided abbreviations.
4
Provide the provider's information, including name, address, and phone number.
5
Sign the form as a parent and have the provider/system admin sign it as well.

Who needs the Confirmation of Child Care Provider Form?

1
Parents looking to enroll their child(ren) in a child care facility and need to confirm the chosen provider.
2
Child care providers who are required to complete and sign the form for enrollment.
3
System administrators responsible for managing child care providers and verifying enrollment details.
4
Parents using multiple child care providers for different children and need to submit separate forms for each provider.
5
Child Care Resource and Referral Agencies verifying child care provider details before issuing vouchers.

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1
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What are the instructions for submitting this form?

What is the purpose of this form?

Tell me about this form and its components and fields line-by-line.

What happens if I fail to submit this form?

How do I know when to use this form?

What are the instructions for submitting this form?

To submit this form, you need to ensure all required fields are completed and both parent and provider have signed it. You can submit the completed form via email to the Child Care Resource and Referral Agency, fax it to the provided fax number, or upload it via the online submission form on the agency's website. If required, deliver a physical copy to the agency’s address. Always keep a copy for your records. If you have further questions, contact the agency directly for assistance.

What is the purpose of this form?

The purpose of this form is to confirm the child care provider chosen by the parent for taking care of their child(ren). It serves as a crucial step in the enrollment process, ensuring that all necessary information is accurately provided and confirmed by both the parent and the provider. By completing and signing this form, the process of obtaining a voucher for child care services is facilitated, ensuring the child's enrollment is verified and approved.

Tell me about this form and its components and fields line-by-line.

This form contains essential fields required for confirming the chosen child care provider and ensuring accurate enrollment details. Each component/field is critical and must be filled accurately.

1. Parent Name: Full name of the parent which is to be filled in this field.
2. Parent Contact Number: Contact number of the parent for any communication purposes.
3. Child #1 Name: Full name of the child which is to be filled in this field.
4. Child #2 Name: Full name of the child which is to be filled in this field.
5. Child #3 Name: Full name of the child which is to be filled in this field.
6. Child #4 Name: Full name of the child which is to be filled in this field.
7. Program Type: Type of child care program each child is enrolled in, using given abbreviations.
8. Provider Information: Information about the child care provider including name, address, and phone number.
9. Date of Enrollment: The expected date of enrollment for each child.
10. Voucher Start Date: Latest date the voucher can start for child to be enrolled.
11. Time of Care: Full/Part-time indication of time of care provided.
12. Days of Care: Days of the week when the care will be provided.
13. Transportation Services: Indicate if transportation services are requested and its approval status.
14. Parent Signature: Signature of the parent to confirm the information provided.
15. Provider Signature: Signature of the provider/system admin to confirm the information provided.
16. Provider Email: Email address of the provider for further communication.

What happens if I fail to submit this form?

If you fail to submit this form, your child's enrollment might not be confirmed, and the voucher issuance may be delayed.

Enrollment Issues: Failure to submit may result in inability to enroll your child in the chosen program.
Voucher Delays: It may cause delays in voucher processing and childcare cost coverage.

How do I know when to use this form?

Use this form when confirming the chosen child care provider for enrollment and voucher issuance.

1. Enrollment Confirmation: Confirm the enrollment of your child(ren) with a chosen child care provider.
2. Voucher Issuance: Ensure accurate information is provided for timely voucher processing.

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