Common use of Licensed Providers Clause in Contracts

Licensed Providers. Do you receive funding from any other source for this child? Check all that apply:  School Readiness  State Head Start  Federal Head Start  DSS CDC  DSS BAS Relative and In-Home Providers: Are you related to this child?  Yes  No If related, specify your relationship below:  Grandparent/Great Grandparent  Aunt/Uncle  Sibling  Niece/Nephew  First Cousin/Second Cousin  Other: CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (Circle AM or PM). SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM

Licensed Providers. Do you receive funding from any other source for this child? Check all that apply:  School Readiness  State Head Start  Federal Head Start  DSS CDC  DSS BAS Relative and In-Home Providers: Are you related to this child?  Yes  No No If related, specify your relationship below:  Grandparent/Great Grandparent  Aunt/Uncle  Sibling  Niece/Nephew  First Cousin/Second Cousin  Other: CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (Circle AM or PM). SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PMPM Is the schedule the same each week?  Yes  No If no, explain how the schedule varies: ► Section 4: Provider Certification: (To be Completed by the Child Care Provider) To the best of my knowledge, I certify that:

Licensed Providers. Do you receive funding from any other source for this child? Check all that apply:  School Readiness  State Head Start  Federal Head Start  DSS CDC  DSS BAS Relative and In-Home Providers: Are you related to this child?  Yes  No No If related, specify your relationship below:  Grandparent/Great Grandparent  Aunt/Uncle  Sibling  Niece/Nephew  First Cousin/Second Cousin  Other: CHILD’S CARE SCHEDULE: Fill in the time the child is in your care (Circle AM or PM). SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM FROM AM PM AM PM AM PM AM PM AM PM AM PM AM PM TO AM PM AM PM AM PM AM PM AM PM AM PM AM PM