STATE OF FLORIDA
VOLUNTARY PREKINDERGARTEN
EDUCATION PROGRAM
Child Attendance and
Parental Choice Certificate
(SHORT FORM)
1. Child’s first name
Middle name
Last name
Jr./III
2. Child’s date of birth
3. Name of private provider or public school
4. VPK class
PARENTAL CERTIFICATION
I swear (or affirm) that my child
attended the Voluntary
(whose name appears above in item 1)
Prekindergarten Education Program during the months listed below. I certify that my child’s
daily attendance in the program was recorded by the private provider or public school and
that I or my representative signed the attendance record each day that my child attended the
program. I further certify that I continue to choose the private provider or public school
(whose
to deliver the program for my child and direct that program funds be
name appears above in item 3)
paid to the provider or school for my child.
5. Attendance
6. Print name of parent or
7. Signature of parent or
8. Date signed
month and year
guardian
guardian
NOTICE TO P RIVATE PROVIDER OR PUBLIC SCHOOL: A private provider or public school must keep this
original signed form for at least 2 years. A private provider must allow the early learning coalition, and a public
school must allow the school district, to inspect this original signed form during normal business hours. If required
by the early learning coalition, a signed copy of this certificate must be forwarded to the coalition or a qualified
contractor acting on behalf of the coalition.
Form
OEL-VPK 03S
(02/14/2007)
STATE OF FLORIDA
VOLUNTARY PREKINDERGARTEN
EDUCATION PROGRAM
Child Attendance and
Parental Choice Certificate
(SHORT FORM)
1. Child’s first name
Middle name
Last name
Jr./III
2. Child’s date of birth
3. Name of private provider or public school
4. VPK class
PARENTAL CERTIFICATION
I swear (or affirm) that my child
attended the Voluntary
(whose name appears above in item 1)
Prekindergarten Education Program during the months listed below. I certify that my child’s
daily attendance in the program was recorded by the private provider or public school and
that I or my representative signed the attendance record each day that my child attended the
program. I further certify that I continue to choose the private provider or public school
(whose
to deliver the program for my child and direct that program funds be
name appears above in item 3)
paid to the provider or school for my child.
5. Attendance
6. Print name of parent or
7. Signature of parent or
8. Date signed
month and year
guardian
guardian
NOTICE TO P RIVATE PROVIDER OR PUBLIC SCHOOL: A private provider or public school must keep this
original signed form for at least 2 years. A private provider must allow the early learning coalition, and a public
school must allow the school district, to inspect this original signed form during normal business hours. If required
by the early learning coalition, a signed copy of this certificate must be forwarded to the coalition or a qualified
contractor acting on behalf of the coalition.
Form
OEL-VPK 03S
(02/14/2007)