Please use the following Program Type Abbreviations when completing the section above: IN (Infant); TO (Toddler); PS (Preschool);
HS (Headstart); NU (Under 2 w/ Independent Provider); NO (Over 2 w/ Independent Provider); SU (Under 2 w/ System Provider); SO
(Over 2 w/ System Provider); AS (After School); BS (Before School); BA (Before & After School); SC (School Closures Only)
Feeding Assistance Expertise
Responding to Emergencies
Grooming and Bathing Assistance
Recording Vital Signs
Admitting Support
Documenting Behaviors
Dementia and Alzheimer's Knowledge
Range of Motion Exercises
Bed Transfers
Output Monitoring and Reporting
Accomplishments
PROVIDER INFORMATION - To be completed by the Child Care Provider:
What is your program/agency name, address and phone number?
(Systems: Please write the provider Name, Address, and your agency)
What is the expected date of enrollment for the child (ren)?
Please verify the earliest date the child can start
What is the latest date the voucher can start and you will agree to take the child
(If the voucher
must start after the date provided, the Child Care Resource and Referral Agency will contact you to confirm the
opening
Otherwise, this form will serve as confirmation for the child to enroll)
How many absences are you willing to accept prior to enrolling?
Please refer to EEC’s Attendance Policy
Please circle one Full time or Part time
Please circle the days care will be provided Su-M-Tu-W-Th-F-Sa
Please circle one- Is the parent requesting transportation services to be included on the
voucher
(Subject to approval by the Child Resource and Referral Agency)
No
Yes- One Way
Yes- Two Way
This form is NOT confirmation that a voucher will be issued
Pursuant to your Voucher Agreement, you will only be reimbursed for
enrolled children with a signed, current voucher
Children are not considered enrolled in subsidized care until the first day the child
actually attends the program following the start date indicated on the voucher.
Elementary School Teacher at Greenhalge Elementary School – Lowell Public SchoolsElementary School Teacher at Greenhalge Elementary School – Lowell Public Schools