Fillable Self Certification Statement (Child Care Aware)

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Self Certification Statement (Child Care Aware)

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The Self Certification Statement (Child Care Aware) form is 1 page long and contains:

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  • 23 other fields

Country of origin: US
File type: PDF

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Self Certification Statement
MILITARY SPONSORED CHILD & YOUTH PROGRAMS
CHILD/YOUTH ELIGIBILITY FORM
This form is used to determine child/youth eligibility for the Military Child Care Fee Assistance and Respite
programs administered by Child Care Aware® of America in the absence of a birth certificate, military
identification card or orders identifying the eligible child(ren)/youth.
Name/Rank of Military Sponsor:
Name of Person Completing this Form:
Relationship to Sponsor (e.g., spouse, designated legal guardian,
other)
By virtue of their relationship to this Military Sponsor (biological, adoption, step
child(ren), legal guardian, or other relationship which authorizes eligibility) the
children listed below are eligible to participate in military sponsored child and
youth programs. Misrepresentation or falsifying this information may subject the
individual to prosecution under the Uniform Code of Military Justice (UCMJ)
and/or applicable State and Federal Laws.
Name of Child
D.O.B
Relationship to Sponsor
Signature of Person Completing Form: (Electronic signature will not be accepted)
Relationship to children listed above:
Date:
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Self Certification Statement (Child Care Aware)

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Completed 20 January 2021

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