D1IS/CC: II (5/07)



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D1IS/CC: II (5/07)

COMPLETE for,EACH three- and four-year-old child for whom Abbott child care wraparound services is wanted or needed:

C .lid care wraparound services are defined as: j

Four hours of part-time child care before and/or after the six-hour program of preschool instruction for ten months (i.e., during the 180 day school calendar year) that at a minimum meet DCF licensing requirements for child care centers; and Ten hours of program operation to enable children to receive full time child care for six hobrs or more hours for two months (i.e.. during the summer months when schools are closed). Program must meet DCF licensing requirements. Children must be actively enrolled and participating in the Abbott Preschool Program. Criteria for eligibility is based on age and residency requirements defined by each Abbott School District.


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1. Last Name (Child #1):




F

-"irst Name:

*4

M.I.

Social Security Number or Alien Registration Number (OplionalA/oluniary)

ji;

Checkilf no number J |

Birth Date (mm/dd/yyyy) " Hispanic or Latino (Check If yes)

Sex Enler M or F)

i ;'







Racej | | j American Indian or Alaskan Native | | Asian

I I Black or African American | | Native Hawaiian/Pacific Islander | | Whlta
1 '

Check 6rie or both to request type of service for which you are applying Nam

e of licensed Abbott child care center site location If child Is currently enrolled: paround i ervics start date: / /

. Part-Time B^tore/After Child Care (lOMonlh School Calendar Year)

Full Time Summer Care (2 Months: July & August) wra

n

or desalt e If child has any Identified special needs:

2. Last Name (Child #2):

i




i

First Name:

M.I.

i i Social Security Number or Alien Registration Number (Opllonal/Voluntary)

i -

Check if no number. | |

Birth Date (mm/dd/yyyy) Hispanic or Latino (Check If yes)

r~ 1

Sex

(Enter M or F)

1







'Race: [ |j American Indian or Alaskan Native | [ Asian | | Black or African American | [ Native Hawaiian/Pacific Islander j [ Whlla

Check one or f otfi to request type of service for which you are applying Na

ma of licensed Abbott child care center site location if child Is currently enrolled: •aparound service start date: II "*

Part-Time Before/After Child Cara (10 Month School Calendar Year)

CH

Full Time Summer Care (2 Months: July & August) w

L,S

t or describe If child has any Identified special needs:

3. Last Name (Child #3):







First Name:

M.I.

Social Security Number or Alien Registration Number (OptionalA/oluntary)

Check If no number: | j

Birth Date (mm/dd/yyyy) Hispanic or Latino (Check If yes)

1 1

Sex

(Enter M or F)













Native Hawaiian/Pacific Islander

Black or African American


American Indian or Alaskan Native

R

Check one or botti to request type of service for which you are applying

Name of licensed Abbott child care center site location If child is currently enrolled: Wraparound service start dale: / /

irt-Time Before/After! Child Cara i ill Month School Calendar Year)

n

Full Time Summer Care (2 Months: July & August)

o

List or describe if child has any Identified special needs:

CERTIFICATION - READ CAREFULLY BEFORE SIGNING

I (we) hereby certify that all of the information that I (we) have provided is true and correct to the best of my (our) knowledge. I (we) understand that knowingly submitting false information about my (our) situation, failing to give the necessary

information or causing others to hold back information is against the law and may subject me (us) to prosecution. I (we) also understand that:

  1. Acceptance of child care financial assistance is not for my (our) personal use or expenses and that federal, state and local public funds are and will be used as payment for costs that are directly associated with services rendered by at
    eligible child care provider.

  2. It is unlawful to obtain financial assistance for child care services by providing any false or misleading information, including but not limited to information about my eligibility and/or information that relates to child attendance for providei
    records, sign-in sheets or voucher payment forms. Examples of unlawful behavior Include, but are not limited to:

9 Pre-signlng and dating voucher certification forms, sign-in sheets or other provider records used to track and verify child attendance.

Failing to accurately verify child attendance on voucher payment records/forms within the reporting timeframes.

3. Providing the requested information, including ths Social Security Number or Alien Registration Number of each family member, is voluntary. Agency staff may use my (our) name and Social Security or Allen Registration information witr
federal and state agencies and other sources deemed necessary for official examination and to verify the accuracy of the information submitted.

  1. Providing false or misleading information in connection with my (our) application for child care financial assistance, and/or failing to report within ten days any change that might change my (our) eligibility, such as a change of residency, ma)
    result in the termination of my (our) child care subsidy.

  2. If I (we) receive financial assistance as a result of false or misleading information. I (we) may be responsible to repay the costs of child care and may be subject to a civil fine and possible criminal prosecution.

Dale: _ Date:


Signature of Applicant/Parent/Guardian:

Signature of Co-Applicant/Parent/Guardian:

Complete reverse side of this application form. A copy of this document will be provided to you for your records.



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