Childcare Provider Change Request Form Page 2

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Cuyahoga County Department of Employment & Family Services
Request to Change Full time Service Hours for Spring/Summer/Winter Break
Parent/Caretaker Name: _________________________________________ Date___________________
Case Number or SS#: _______________________________
Phone Number: ______________________
Complete this form if you need to change your childcare provider hours to FULL TIME for School Break
Please allow 10 days for processing
Name of Child/Social Security
Provider Name
Provider Id
School Break Begin
School Break End
Number
Number
Date
Date
Parent/Caretaker Signature: _____________________________________________________
Date: __________________
Childcare Worker: ___________________________________
Childcare Information Line: 216 987-6929 / Fax Number: 216 987-8655
Employment & Family Services
1641 Payne Avenue, Cleveland, Ohio 44114
(216) 987-7000
Ohio Relay Service (TTY) 711

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