Weekly Child Attendance Form
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1DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILDCARE & EARLY CHILDHOOD EDUCATION
WEEKLY CHILD ATTENDANCE FORM
Facility Name_____________________________________
Facility Number______________
Week of__________________________
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
Sunday
Monday
Tuesday Wednesday Thursday
Friday
Saturday
Parent Signature**
Date
TIME
1
IN
OUT
2
IN
OUT
3
IN
OUT
4
IN
OUT
5
IN
OUT
6
IN
OUT
7
IN
OUT
8
IN
OUT
9
IN
OUT
10
IN
OUT
11
IN
OUT
12
IN
OUT
13
IN
OUT
14
IN
OUT
15
IN
OUT
Provider Certification: 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.
**Parent signature is required as disclosed in the 9800 agreement for payment of vouchers.
DHS 9800 A2W (7/1/2007)
Director/Owner Signature
Date
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