Education Schedule Verification Form - Child Care Information Services Of Berks County, Pennsylvania Page 2
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2SUBSIDIZED CHILD CARE
EDUCATION VERIFICATION
Dear Education Administrator:
One of your students has requested assistance with their child care costs while they continue their education. We must verify
their enrollment and schedule in your educational program. This information will help us determine your student's eligibility for
subsidized child care.
We must have an accurate record of your student's schedule. This form has been provided for this purpose. When completed
by you, this form will satisfy our need for this information per regulations. It is very important that the hours shown are specific
and defined as either AM or PM (e.g. 7:30am - 3:30pm).
Thank you for your time and assistance. If you have any questions about the program or regarding how to complete the
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Education Verification form, please contact the Child Care Information Services (CCIS) agency below.
CHILD CARE INFORMATION SERVICES AGENCY:
Helping families find, select, and pay for quality child care.
CHILD CARE
INFORMATION
SERVICES OF BERKS COUNTY
A program of the Berks County Intermediate Unit
610-987-CCIS (2247)
800-257-3038
N
N
1111 Commons Boulevard
P.O. Box 16050
Reading, PA 19612-6050
N
FAX: 610-987-8428
An authorized representative (not the student) MUST complete the
shaded areas on the front and back of this Education Verification form.
I hereby verify that I am an authorized representative and attest
that the information on this form is true and correct.
Name of Training Institute/College
Authorized Signature
Address of Training Institute/College
Print Name
Telephone Number
Date
Your Title
For the Student:
I hereby authorize and request the disclosure to the Child Care Information Services (CCIS) agency
all information contained in this form to verify and assess my eligibility for the Subsidized Child
Care Program.
Signature of Student
Date
Print Name
CD 924 7/07
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