Child Care Verification Form

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STAFFORD COUNTY PUBLIC SCHOOLS
CHILD CARE VERIFICATION
(PLEASE PRINT)
INSTRUCTIONS: Parents or guardians requesting a student transfer based on child care in a school attendance area
other than their own must complete PART I, and have the Child Care Provider complete PART II of this form. The parent
or guardian must attach this completed form to the transfer request. The child care location must be in the same
attendance area as the requested school. A separate form must be completed for each child.
PART I
STUDENT/PARENT INFORMATION
Student’s Name: ______________________________________________________________ Grade Level: ________
LAST
FIRST
MI
Base School: ________________ Requested School: __________________ For School Year: ________ ---- ________
Parent/Guardian Name: _____________________________________________________________________________
Address:
_______________________________________________________________________________________
STREET
APT #
_______________________________________________________________________________________
CITY
STATE
ZIP CODE
Phone:
__________________________________
Email: _____________________________________________
Parent/Guardian Signature: ________________________________________________ Date: ____________________
PART II
CHILD CARE PROVIDER INFORMATION
Child Care Provider: ________________________________________________________________________________
Address of Provider: _______________________________________________________________________________
STREET
APT #
_______________________________________________________________________________
CITY
STATE
ZIP CODE
Provider’s Phone:
_______________________________
I certify that I am, and/or this company is, providing child care to the above-named child.
Provider’s Signature _________________________________________________________ Date _________________
Title/Position: ______________________________________________________________
PART III
REQUESTED SCHOOL VERIFICATION (for office use only)
Select ONE:
It is verified that this child care provider is located in the attendance area of the requested school.
It is verified that this child care provider is NOT located in the attendance area of the requested school.
Verified by: _________________________________________
Position: _____________________________________
Signature: _____________________________________________________
Date: ____________________________
Submit completed Child Care Verification form with Student Transfer Application to the Student Transfer Office.
Student Transfer Office
Revised 1/1/11

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