Class/training - Verification Form (Page 2 of 2) in pdf

SUBSIDIZED CHILD CARE

CLASS / TRAINING VERIFICATION

Dear Administrator:

One of your students/trainees has requested assistance with his child care costs while he participates in class/training. The

Child Care Information Services (CCIS) agency must verify the student’s/trainee’s enrollment and schedule indicating when he

attends your institution’s education/training program. This information will help determine your student’s/trainee’s eligibility for

the Child Care Works program.

The CCIS must have an accurate schedule. This form has been provided for this purpose. It is very important that the hours

shown are specific and defined as either AM or PM (e.g., 7:30am - 3:30pm).

Thank you for your time and assistance. If you have any questions about the Child Care Works program or regarding how to

complete this form, please contact the CCIS agency below.

CHILD CARE INFORMATION SERVICES AGENCY:

Child Care Information Services of Bucks County/ Apple Child Care Services

70 W. Oakland Ave. Suite 210

Doylestown, PA 18901-4214

1-800-371-2109

(215) 348-1283

FAX NUMBERS:

215-230-1979

215-348-9397

215-348-0725

(All fax numbers will work, but use circled fax number if one is circled)

Additional copies of this form and others are available at

An authorized representative of the educational/training institution (not the student/trainee) MUST complete the shaded areas on

the front and back of this form.

I hereby verify that I am an authorized representative of the educational/training institution and attest that the information on

this form is true and correct.

Name of Educational/Training Institution

Authorized Signature

Address of Educational/Training Institution

Printed Name

Your Title

Telephone Number

Date

For the Student/Trainee:

I authorize and request the disclosure to the CCIS agency all information contained in this form to verify my enrollment

and schedule, as well as to assess my eligibility for the Child Care Works program.

Signature of Student/Trainee

Date

Printed Name

CD 930 12/07

Class/training - Verification Form Page 2