Pathways Generic Attendance Record
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2Use standard time (not military).
Use permanent ink, no white out.
If you make a mistake, cross it out neatly and initial.
FOR RECORD KEEPING PURPOSES ONLY.
Generic Attendance Record
You have applied for child care and development services. If you are approved, the following information is required. Completion of this form does not guarantee
reimbursment until you receive written notification. This is for record-keeping purposes only. In order for this to be a reimbursable record, all applicable sections below must
be completed.
Provider Name:
Month:
Parent Name:
Child Name:
Child's Birthdate:
PARENTS* ONLY
PROVIDER ONLY
PARENTS* ONLY
Day of
Time In
Full Parent* Signature
Time Out
Provider Initials
Time In
Provider Initials
Time Out
Full Parent* Signature
Month
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*A parent or other previously authorized adult must indicate exact time and sign in/out daily.
By signing, I certify under penalty of perjury that the information indicated on this attendance record is true and accurate.
The information was recorded daily.
Provider Signature
Date
Parent Signature
Date
(Cannot be signed before the last day of child care for this month is over.)
Attendance web form
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