An Application Packet Page 5
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14Parent Acknowledgement Form
Certification Statement
Case Name: _____________________________________________
Case #
_________________
Before you sign this form, please read it carefully to be certain that all of your questions are answered.
When you have finished reading this form, please sign and date the form. The signed and dated
Acknowledgement Form must be returned to Workforce Solutions Northeast Texas before placement and
at each recertification. Understand that this is temporary funding and can end at anytime if you become
ineligible or funding has been exhausted.
SECTION I
A child care representative will answer any questions you may have regarding the Parent Handbook. The
Parent Handbook has been developed to help parents understand their rights and responsibilities to
receive child care assistance through Workforce Solutions Northeast Texas.
SECTION II
I ACKNOWLEDGE:
I spoke with a child care representative, who explained available services and the intake process
for accessing those services; (Page 4 in Parent Handbook).
My rights and responsibilities were explained; (Page 12 in Parent Handbook)
I was given information about different types of child care; (Page 4-6 in Parent Handbook).
I was allowed to select the child care arrangement that my family needs; and understand that I
must call Workforce Solutions to request a client services specialist set up child care at the
chosen provider before care can be authorized to start. (Page 4-6 in Parent Handbook)
I understand my responsibilities regarding my child’s child care arrangements; (Pages 6-13 in
Parent Handbook)
I was given an explanation of my parent share of cost; (Page 10 in Parent Handbook)
I was informed that I must report a change within 10 calendar days; (Page 10 in Parent
Handbook)
I was given an explanation of the attendance/absences policy; (page 13 in Parent Handbook)
I was informed that 25 hours per week is the minimum number of employment and/or education
hours for a one parent household and 50 hours per week for a two parent household; (Page 12 in
Parent Handbook)
I was given an explanation of orientation to complaint, the fraud policy, and the appeals process;
(Pages 15-17 in Parent Handbook)
I was given the address and telephone number for contacting Workforce Solutions Northeast
Texas Child Care Services. (Page 3 and Page 17 in Parent Handbook)
SECTION III
I AGREE to pay a Parent Share of Cost (Parent Fee), if applicable, to the child care provider where
my child is receiving care, in advance of my child receiving child care services. I understand that my
parent fee is based on my family’s gross income, family size, and the number of children enrolled in child
care.
I AGREE to comply with the provisions of the Parent Enrollment Agreement (Page 9 in Parent
Handbook).
Updated 04-13
Form CS008
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