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Request to Reduce Child Care Hours

Full Name:
Date:

I'm requesting change for the following child(ren):

1. Child

Child Name:
Date of Birth:

Current Hours Authorized

Please write the number of hours per day.
Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:

New Hours Requested

Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:
Effective Date of Change:

2. Child

Child Name:
Date of Birth:

Current Hours Authorized

Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:

New Hours Requested

Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:
Effective Date of Change:

3. Child

Child Name:
Date of Birth:

Current Hours Authorized

Please write number of hours per day.
Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:

New Hours Requested

Mon:
Tues:
Wed:
Thurs:
Fri:
Sat:
Sun:
Effective Date of Change:

Parent

Name:
Family ID:
By checking this box, I acknowledge that I understand my right to continue using child care services based on my current authorized hours of care. However, I understand that I am requesting a reduction in authorized hours of care and this request is voluntary: