Child’s Name:
Child’s Name:
|Item Number: |Payment date: |For care during: |Comments: |Amount Paid for Care: |Late Fees Paid: |Check number: |
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| | | |Sub-Total: |0 |$0 | |
|Other payments (such as deposits, supply fees, enrollment fees, field trip fees, etc): |
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| | | |TOTAL: | | | |
| |Signatures: |Date Signed: |
|Parent or Guardian: | | |
|Parent of Guardian: | | |
|Child Care Provider: | | |
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