Dhr/cca 8506 - All About Form (Child Care Administration) Page 4

MY CHILD HAS DIFFICULTY WITH THES ACTIVITIES

MY CHILD WILL NEED THE FOLLOWING EQUIPMENT AND/OR ROUTINES

THINGS MY CHILD MIGHT NEED HELP WITH

WHAT SPECIAL ADAPTATIONS WILL THE PROGRAM MAKE AT THIS TIME?

(For the use of the Child Care Facility when needed)

This information is intended for use by the child care provider, developed in cooperation with the parents.

THIS IS NOT INTENDED TO BE A LEGALLY BINDING CONTRACT.

Signatures:

Parent/Guardian: _____________________________________________________________ Date: _______________

Provider: ___________________________________________________________________ Date: _______________

Updates:

Parent/Guardian: ______________ Date: ___________

Parent/Guardian: _________________ Date: __________

Provider: ______________________________________

Provider: ________________________________________

DHR/CCA 8506 (6/98) Side 2 of 2

Webform – After School Connections Version 3/06/2001 Page 10

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Parent category: Legal