Form Cc-218-Pd - Sign-In/sign Out Record
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
CC-218-PD (7-14)
SIGN-IN/SIGN-OUT RECORD
PENALTY WARNING: By signing this document the parent, guardian, or other authorized person verifies, under penalty of perjury, that the times recorded are the actual times the child was in attendance.
CHILD CARE PROVIDER’S NAME
CHILD’S NAME
PARENT/GUARDIAN’S NAME
MONTH AND YEAR
Time In
Time Out
Time In
Time Out
Unit
Date
Signature
Signature
Signature
Signature
AM
AM
PM
PM
of Care
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PENALTY WARNING: The submission of billing claim forms for the child named on this record constitutes verification by the Provider, under penalty of perjury, that this document is a true and accurate
record of signatures, dates, and time of service.
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