Ccdf High School Verification Form - Brightpoint printable pdf download

Ccdf High School Verification Form - Brightpoint

CHILD CARE and DEVELOPMENT FUND (CCDF) VOUCHER PROGRAM

SECONDARY SCHOOL ENROLLMENT VERIFICATION

(v10-14)

By my signature below, I give consent to __________________________ to release my enrollment information to the

CCDF Intake Office listed below. This information is necessary to establish my eligibility for child care assistance.

Student (CCDF Applicant) Signature _______________________________________________

Printed Name ______________________________________

Date _____________________

For School Use Only:

Student’s Street Address: ___________________________________________________________

Student’s City _________________________________

Student’s Zip Code ________________

Student’s Current Grade Level _________________ Anticipated Graduation Date ____________

Date Year Begins _________________________ Current Year Ends ________________________

Student’s School Day Begins __________

PM Student’s School Day Ends __________ PM

Check Days Attending:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

School Name: ____________________________________________________________________

School Address: __________________________________________________________________

Phone: _____________________________________ Fax: ________________________________

Completed by: ______________________________________ Date _________________________

Printed Name: ______________________________________ Title _________________________

PLEASE RETURN FORM TO:

Brightpoint Attn: Family Support

PO Box 10570

Fort Wayne, IN 46853

Phone: (260)423-3546 Follow automated prompts for Child Care questions.

Fax: (260)420-8067

Email:

Ccdf High School Verification Form - Brightpoint