Child Care Assistance Program Attendance Record

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CHILD CARE ASSISTANCE PROGRAM
ATTENDANCE RECORD
Provider:
Month/Year:
Program:
Child Name:
Child DOB:
Parent Name:
Case Worker:
Provider Type:
Provider Phone:
FAMILY FEE CERTIFICATION & RECEIPT
PART TIME MONTHLY FEE: $
FULL TIME MONTHLY FEE: $
(Please Check One Box)
Parent Signature & Date
☐ All Family Fees have been paid.
Amount Collected: $____________
☐ A Payment Plan is in place between the parent and provider.
Provider Signature & Date
Amount Collected: $____________
☐ Family Fees have not been paid and I do not have a payment plan in
place.
Outstanding Balance: $____________
A
M
B
C
D
TTENDANCE
UST
E
OMPLETED
AILY
Time In
Time Out
Time In
Time Out
Time In
Time Out
Time In
Time Out
Date
Day
Date
Day
(AM/PM)
(AM/PM)
(AM/PM)
(AM/PM)
(AM/PM)
(AM/PM)
(AM/PM)
(AM/PM)
PARENT Self-Certification
PROVIDER Self-Certification
As a parent, I declare under penalty of perjury that the information above is an
As the provider, I declare under penalty of perjury that the information above is
accurate record of child care provided and that during this time period I was
true and correct, and that the child care as stated above was provided. I
employed, or attending training/school, or other qualifying activity.
understand that I may be required to repay any overpayment.
Parent/Guardian Signature:
Date:
Provider Signature:
Date:
Pathways LA • 3325 Wilshire Blvd Suite 1100 • LOS ANGELES, CA 90010-1703 • (213) 427-2700

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