Child Care Sign In / Sign Out Sheet Page 2
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1
2URBAN AREA
CHILD CARE SIGN IN/OUT SHEET
FOR OFFICIAL USE ONLY
Before School (BS)
After School (AS)
___
Before & After (BA)
TOTAL HOURS:
(8 hours or less)
TOTAL FULL TIME DAYS:
BS RATES:
$
X
HRS =
$
AS RATES:
$
X
HRS =
$
BA RATES:
$
X
DAYS = $
HOURLY RATES: $
X
HRS =
$
DAY RATES:
$
X
DAYS = $
TOTAL HOURS + DAYS =
$
_________
PARENT PERCENTAGE =
%
PARENT/GUARDIAN OWES PROVIDER:
$
CCDF OWES PROVIDER =
$
PAYMENT AUTHORIZED BY:
CCDF COORDINATOR
DATE
PROVIDERS ONLY
PARENTS ONLY
Is client’s co-payment current? Yes
No
If NO, balance owed:
By signing this sheet, the Parent validates the child
By signing this sheet, the Provider validates the child
care hours and payments agreed for the provider.
care hours and payments agreed for the provider.
PROVIDERS SIGNATURE
PARENT/GUARDIAN SIGNATURE
DATE
DATE
Revised 1/2915
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