M
T. SAN JACINTO COLLEGE DISTRICT
1499 NORTH STATE STREET SAN JACINTO CA 92583
(951)
487-3292
CHILD CARE VERIFICATION
STUDENT INFORMATION
Name: ____________________________________ ___ ____________________ ________________________
MSJC ID Phone
Address: _________________________________________________________________________________________
City State/Zip
List name, gender and age of child(ren) needing care: PLEASE PRINT
1. ___________________________________________________ 4. ________________________________________________
Name Gender Age Name Gender Age
2. ___________________________________________________ 5. ________________________________________________
Name Gender Age Name Gender Age
3. ___________________________________________________ 6. ________________________________________________
Name Gender Age Name Gender Age
7. ___________________________________________________ 8. ________________________________________________
Name Gender Age Name Gender Age
1). A CARE grant is needed to help pay for: (Check all that apply)
Evening course Saturday course Week day course Study hours Co-Pay
(If you have a co-pay you must
Submit a copy of your contract.)
2). Does the Department of Social Services or RCOE pay your childcare while you attend class? Yes No
3). How much do you expect to pay each month for childcare above what other agencies pay? $ ____________
I certify that the information above is true and correct. I am aware that a CARE grant is awarded based on my financial need. I agree to pay my
childcare provider for services rendered, and I understand that it is my responsibility to uphold any agreement made between the provider and myself
.
________________________________________ _______________________________
Signature Date
CHILDCARE PROVIDER INFORMATION
Name: _____________________________________________________ Phone: __________________________________
Address/City/ Zip: ______________________________________________________________________________________
1). How many hours per week do you provide childcare while the parent attends class? ________
2). Do you receive payment from GAIN or any other agency for the hours indicated in question #1? Yes No How many? ______
3). Please indicate the number of hours per week you provide childcare while the parent studies? ________
4). HOW MUCH DO YOU CHARGE? HOURLY _________ WEEKLY _________ MONTHLY _________
I understand that any agreement to provide childcare services for the above student is solely between the student and me. I am also aware that the
disclosed information is to be used to verify that I provide childcare for the above student and to establish the student’s need for child care services.
_________________________________________________________ ___________________________________________
Signature Date
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