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School Form

Instructions

Please list all children who are currently receiving child care and developmental program whether or not the child is in school. If child is attendingHeadStart Program, State Preschool Program, School (K-6), or other subsidized or non-subsidized child care program, please complete all boxes. If child isnotenrolled in any programs, please put in N/A.
If your child is attending private school, you need to submit a school calendar.
Please complete and return.

1. Child

Child's Name:
School's Name:
School District:
Year Round School?:

School Schedule

Monday

Start Time:
End Time:

Tuesday

Start Time:
End Time:

Wednesday

Start Time:
End Time:

Thursday

Start Time:
End Time:

Friday

Start Time:
End Time:

2. Child

Child's Name:
School's Name:
School District:
Year Round School?:

School Schedule

Monday

Start Time:
End Time:

Tuesday

Start Time:
End Time:

Wednesday

Start Time:
End Time:

Thursday

Start Time:
End Time:

Friday

Start Time:
End Time:

3. Child

Child's Name:
School's Name:
School District:
Year Round School?:

School Schedule

Monday

Start Time:
End Time:

Tuesday

Start Time:
End Time:

Wednesday

Start Time:
End Time:

Thursday

Start Time:
End Time:

Friday

Start Time:
End Time:

4. Child

Child's Name:
School's Name:
School District:
Year Round School?:

School Schedule

Monday

Start Time:
End Time:

Tuesday

Start Time:
End Time:

Wednesday

Start Time:
End Time:

Thursday

Start Time:
End Time:

Friday

Start Time:
End Time:

5. Child

Child's Name:
School's Name:
School District:
Year Round School?:

School Schedule

Monday

Start Time:
End Time:

Tuesday

Start Time:
End Time:

Wednesday

Start Time:
End Time:

Thursday

Start Time:
End Time:

Friday

Start Time:
End Time:

Yes, make changes to my authorized hours of care, to reflect my child(ren)'s school schedule:
Parent's Name:
Email:
Date:
I certify the above information is true and correct: