School/training Verification Form

Please return to: Early Learning Coalition of Pasco & Hernando Counties

Caseworker: ________________________ Ext. ________

School/Training Verification Form

Parents/Guardians: Only applicable, if Parent(s)/Guardian(s) are attending or going to attend school during the redetermination period.

In order to determine the eligibility for subsidized child care, we must verify school attendance on the below listed client. Please assist us by having the

school/training records office complete Section II and returning this form to the above listed Coalition office as soon as possible.

SECTION I- TO BE COMPLETED BY PARENT/GUARDIAN (STUDENT)

PARENT/GUARDIAN NAME: _____________________________________________________ SSN#: (optional) __________________________

I give permission for my school to release the following information to the Early Learning Coalition of Pasco & Hernando Counties.

_____________________________________________________

_______________________

Parent/Guardian Signature

Date

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SECTION II- TO BE COMPLETED BY SCHOOL RECORDS OFFICIAL

1. Student’s Name ______________________________________________

ID# ______________________________

2. Student’s Address ________________________________________________________________________________

3. Days of Attendance: Mon. From _______ To _______, Tues. From _______ To _______, Wed. From _______ To _______,

Thurs. From _______ To _______, Fri. From _______ To _______, Sat. From _______ To _______, Sun. From _______ To _______,

Course Semester Begins: _______/_______/_______

Course Semester Ends: _______/_______/_______

Number of Hours Student is Currently Enrolled: _________ Clock Hours

_________ Credit Hours

Number of Hours completed last grading period:_________ Clock Hours

_________ Credit Hours

Is this enrollment considered FT / PT / LTPT according to your institution? (Please Circle one).

The documented course load, if less than FT will involve _____ hours of direct education activities, including class, lab, and study time, as well as any

other related activities.

Did student obtain passing grade?

Yes

No

If no, please explain _____________________________________________

_____________________________________________________________________________________________________________

Module Courses Only:

Training Duration (months): _______

Beginning Date: _____/_____/_____

Expected to Graduate on: _____/_____/_____

4. Major or Occupational Goal: _______________________________________________________________________________________

5. Name of School: ________________________________________________________________________________________________

Address of School: _______________________________________________________________________________________________

6. Name of Records Official: _________________________________________________________________________________________

Title of Records Official: __________________________________________________________________________________________

___________________________________________

__________________

____________________________________

Signature of Records Official

Date

Official Seal (As Applicable)

___________________________________________

Phone Number of Records Official