Daycare Information and Agreement

This form provides ��Ƶ with important information about the daycare and student-parent/child(ren) who are being served through the childcare grant program.

Facility Name(Required)
Facility director(s) or representative(s) who will complete monthly attendance verification and points of contact.(Required)
Facility Phone Number(Required)
Email Address(Required)
Mailing Address(Required)
Street Address Address Line 2 City ZIP / Postal Code
Physical Address
If different from mailing address

Street Address Address Line 2 City ZIP / Postal Code
Copy of NC State License or Religious Exemption Letter
Drop files here or

Accepted file types: pdf, Max. file size: 300 MB.
Completed W-9 Form
Drop files here or

Accepted file types: pdf, Max. file size: 300 MB.
Name of Student-Parent(Required)
Name(s) of Child(ren) and their ages(Required)
Current childcare rate for child(ren)(Required)
Childcare rate billed(Required)
- Weekly
- Monthly
Agreement
- I have read and understand all of the information provided on the homepage for the childcare program. I agree to the terms of the program and will complete all necessary paperwork by the 5th of each month by 12 p.m. in order to receive timely payment.
  
  I have completed all of the above information to the best of my knowledge and will provide updated information as needed, in a timely manner.
CAPTCHA

Web Design & Hosting by and

������Ƶ

Childcare Financial Assistance Childcare Vendors

Daycare Information and Agreement

Daycare Information and Agreement

��Ƶ