Form Il444-3455 - Child Care Application - Illinois Department Of Human Services Page 8

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State of Illinois
Department of Human Services - Bureau of Child Care and Development
CHILD CARE APPLICATION
Parent/Guardian Name:
SECTION 4 - CHILD CARE ARRANGEMENT
Name of provider (attach a separate schedule for each provider you are requesting payment for):
Provider Registration Number (Providers without a registration number should contact the CCR&R):
List only the children who will be cared for by THIS child care provider.
If your children go to school, pre-k, or head start at another facility during the day, list only the hours that they are in child care
with THIS provider. For school age children, list only the hours they are in child care.
Usual Schedule of Hours in Child Care
Daily
Rate
Age
MON
TUE
WED
THU
FRI
SAT
SUN
Child's Name
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
Relationship to Client:
AM
AM
AM
AM
AM
AM
AM
TO
PM
PM
PM
PM
PM
PM
PM
Does the child listed attend school?
Yes
No
Year Round
What hours is the child in school?
Is the school at the same location as the provider?
Yes
No
Does this child care schedule vary?
Yes
No
If yes, please explain:
Does the provider offer a multi-child/family discount?
Yes
No
If yes, please explain:
Usual Schedule of Hours in Child Care
Daily
Rate
Age
MON
TUE
WED
THU
FRI
SAT
SUN
Child's Name
AM
AM
AM
AM
AM
AM
AM
FROM
PM
PM
PM
PM
PM
PM
PM
Relationship to Client:
AM
AM
AM
AM
AM
AM
AM
TO
PM
PM
PM
PM
PM
PM
PM
Does the child listed attend school?
Yes
No
Year Round
What hours is the child in school?
Is the school at the same location as the provider?
Yes
No
Does this child care schedule vary?
Yes
No
If yes, please explain:
Does the provider offer a multi-child/family discount?
Yes
No
If yes, please explain:
IL444-3455 (R-6-11)
Page 8 of 17

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