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Fill in the ProviderAgency Name ACCIS, YYYY, Provider Rate All providers except, Indicate the rate charged for each, INFANT Under months, TODDLER months under years, PRESCHOOL years under years, SCHOOLAGE years, Full time hours or more per week, Part time hours per week, Hourly hours per week but less, ATTENTION Regulatedlicensed, and Informal providers must provide areas with any data that may be requested by the platform.
Provide the key details in the Childs Name, Date of Birth, Date Care Began, Weekly Schedule, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday, OFFICE USE ONLY, CHILDS NAME, CHILDS NAME, and CHILDS NAME segment.
The Provider Certification I am, Providers Name print clearly, Signature Date, ParentGuardian Certification I, ParentGuardians Name, ParentGuardians Signature, Date, For Agency Use Only Is child care, Agencyapproved start date for, and YYYY area is the place to insert the rights and responsibilities of both sides.
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