Daily Child Attendance Form printable pdf download

Daily Child Attendance Form

DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILDCARE & EARLY CHILDHOOD EDUCATION

DAILY CHILD ATTENDANCE FORM

Facility Name_____________________ Facility Number ___________ Date of Service ____________

Parent/Guardian/Authorized Representative Certification of Attendance:

By my signature below, I declare

under penalty of perjury that the information is true and that my child/children were provided services at the above

location and on the days and times listed below. I understand that I must repay any overpayment resulting from false or

incorrect information and that I may be prosecuted for fraud.

Child's Name

Time In

Parent Signature**

Time Out

Parent Signature**

Provider Certificaiton: I declare under penalty of perjury that the above information is true and that these children were provided services at the above location and

on the days and times listed above. I understand that I must repay any overpayment resulting from false or incorrect information and that I may be prosecuted for

fraud.

Director/Owner Signature

Date

DHS 9800 A2D (7/1/2007)

**Parent signature is required as disclosed in the 9800 agreement for payment of vouchers.