"School-Age Child Care Schedule (Summer) - Child Care Financial Assistance Program" - Vermont

This "School-Age Child Care Schedule (Summer) - Child Care Financial Assistance Program" is a document issued by the Vermont Department of Children and Families specifically for Vermont residents with its latest version released on March 6, 2015.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Vermont Department of Children and Families.

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Child Care Financial Assistance Program
School-Age Child Care Schedule (Summer)
Attention Parents/Caregivers
Please complete the information below to assure your child care provider is paid correctly for your child(ren)’s
summer schedule. Return this form to the address below:
Parent/Caregiver Name: _________________________________________________________________________
Please note: The Child Development Division (CDD) will not make payments on behalf of parents for deposits,
registrations or any other fee that the provider may charge over and above fees for child care services.
(1)
Child Name: _____________________________
(2)
Child Name: _____________________________
My child’s school is: ____________________________
My child’s school is: ____________________________
Last day of school is: ____________________________
Last day of school is: ____________________________
My school age child will need child care this summer as
My school age child will need child care this summer as
follows:
follows:
Child care provider: ____________________________
Child care provider: ____________________________
Beginning Date _____ / _____ / ________
Beginning Date _____ / _____ / ________
month day
year
month day
year
End Date
_____ / _____ / ________
End Date
_____ / _____ / ________
month day
year
month day
year
Day of week:
Time of day (Circle am or pm)
Day of week:
Time of day (Circle am or pm)
Monday
From _______am/pm to _______am/pm
Monday
From _______am/pm to ________am/pm
Tuesday
From _______am/pm to _______am/pm
Tuesday
From _______am/pm to ________am/pm
Wednesday From _______am/pm to _______am/pm
Wednesday From _______am/pm to ________am/pm
Thursday From _______am/pm to _______am/pm
Thursday From _______am/pm to ________am/pm
Friday
From _______am/pm to _______am/pm
Friday
From _______am/pm to ________am/pm
Saturday
From _______am/pm to _______am/pm
Saturday
From _______am/pm to ________am/pm
From _______am/pm to _______am/pm
From _______am/pm to ________am/pm
Sunday
Sunday
If your provider will be on vacation or unavailable anytime during the summer and your child will be
attending another program, please call your eligibility specialist. In addition, please complete the reverse
side of this form to notify your eligibility specialist of your child care needs for the fall.
Please check this box if your child(ren) WILL NOT be needing child care during the fall school year.
If you have questions regarding completion or submission of this form, please contact
the Community Child Care Eligibility Specialist at the number below:
http://dcf.vermont.gov/cdd
Agency of Human Services
Revised 3/6/2015
Child Care Financial Assistance Program
School-Age Child Care Schedule (Summer)
Attention Parents/Caregivers
Please complete the information below to assure your child care provider is paid correctly for your child(ren)’s
summer schedule. Return this form to the address below:
Parent/Caregiver Name: _________________________________________________________________________
Please note: The Child Development Division (CDD) will not make payments on behalf of parents for deposits,
registrations or any other fee that the provider may charge over and above fees for child care services.
(1)
Child Name: _____________________________
(2)
Child Name: _____________________________
My child’s school is: ____________________________
My child’s school is: ____________________________
Last day of school is: ____________________________
Last day of school is: ____________________________
My school age child will need child care this summer as
My school age child will need child care this summer as
follows:
follows:
Child care provider: ____________________________
Child care provider: ____________________________
Beginning Date _____ / _____ / ________
Beginning Date _____ / _____ / ________
month day
year
month day
year
End Date
_____ / _____ / ________
End Date
_____ / _____ / ________
month day
year
month day
year
Day of week:
Time of day (Circle am or pm)
Day of week:
Time of day (Circle am or pm)
Monday
From _______am/pm to _______am/pm
Monday
From _______am/pm to ________am/pm
Tuesday
From _______am/pm to _______am/pm
Tuesday
From _______am/pm to ________am/pm
Wednesday From _______am/pm to _______am/pm
Wednesday From _______am/pm to ________am/pm
Thursday From _______am/pm to _______am/pm
Thursday From _______am/pm to ________am/pm
Friday
From _______am/pm to _______am/pm
Friday
From _______am/pm to ________am/pm
Saturday
From _______am/pm to _______am/pm
Saturday
From _______am/pm to ________am/pm
From _______am/pm to _______am/pm
From _______am/pm to ________am/pm
Sunday
Sunday
If your provider will be on vacation or unavailable anytime during the summer and your child will be
attending another program, please call your eligibility specialist. In addition, please complete the reverse
side of this form to notify your eligibility specialist of your child care needs for the fall.
Please check this box if your child(ren) WILL NOT be needing child care during the fall school year.
If you have questions regarding completion or submission of this form, please contact
the Community Child Care Eligibility Specialist at the number below:
http://dcf.vermont.gov/cdd
Agency of Human Services
Revised 3/6/2015
Child Care Financial Assistance Program
School-Age Child Care Schedule (Fall)
Attention Parents/Caregivers
Please complete the information below to assure your child care provider is paid correctly for your child(ren)’s
fall schedule. Return this form to the address below:
Parent/Caregiver Name: _________________________________________________________________________
Please note: The Child Development Division (CDD) will not make payments on behalf of parents for deposits,
registrations or any other fee that the provider may charge over and above fees for child care services.
(1)
Child Name: _____________________________
(2)
Child Name: _____________________________
My child’s school is: ____________________________
My child’s school is: ____________________________
First day of school is: ___________________________
First day of school is: ___________________________
My school age child will need child care this fall as
My school age child will need child care this fall as
follows:
follows:
Child care provider: ____________________________
Child care provider: ____________________________
Beginning Date _____ / _____ / ________
Beginning Date _____ / _____ / ________
month day
year
month day
year
End Date
_____ / _____ / ________
End Date
_____ / _____ / ________
month day
year
month day
year
Day of week:
Time of day (Circle am or pm)
Day of week:
Time of day (Circle am or pm)
Monday
From _______am/pm to _______am/pm
Monday
From _______am/pm to ________am/pm
Tuesday
From _______am/pm to _______am/pm
Tuesday
From _______am/pm to ________am/pm
Wednesday From _______am/pm to _______am/pm
Wednesday From _______am/pm to ________am/pm
Thursday From _______am/pm to _______am/pm
Thursday From _______am/pm to ________am/pm
Friday
From _______am/pm to _______am/pm
Friday
From _______am/pm to ________am/pm
Saturday
From _______am/pm to _______am/pm
Saturday
From _______am/pm to ________am/pm
From _______am/pm to _______am/pm
From _______am/pm to ________am/pm
Sunday
Sunday
If your provider will be on vacation or unavailable anytime during the school year and your child will be
attending another program, please call your eligibility specialist. In addition, please complete the reverse
side of this form to notify your eligibility specialist of your child care needs for the summer.
Please check this box if your child(ren) WILL NOT be needing child care during the summer.
If you have questions regarding completion or submission of this form, please contact
the Community Child Care Eligibility Specialist at the number below:
http://dcf.vermont.gov/cdd
Agency of Human Services
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