Child Attendance And Parental Choice Certificate Long Form

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STATE OF FLORIDA
VOLUNTARY PREKINDERGARTEN
EDUCATION PROGRAM
Child Attendance and
Parental Choice Certificate
(LONG 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
5. Attendance month
6. Year
7. Child’s attendance is:
Entered below
<Select One>
See attached document
SUN
MON
TUE
WED
THU
FRI
SAT
= Days attended
PARENTAL CERTIFICATION
I swear (or affirm) that my child
attended the Voluntary
(whose name appears above in item 1)
Prekindergarten Education Program on the days entered above, or included in the
documentation attached to this form, and certify that I continue to choose the private
provider or public school
to deliver the program for my child
(whose name appears above in item 3)
and direct that program funds be paid to the provider or school for my child.
8. First name of parent or guardian
Middle name
Last name
Jr./Sr./III
9. Signature of parent or guardian
10. Date signed
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 permit the early learning coalition, and a public
school must permit 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 03L
(02/14/2007)

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