DEPARTMENT OF CHILDREN AND FAMILIES



DEPARTMENT OF CHILDREN AND FAMILIESDivision of Early Care and EducationCCWSChild Care Authorization WorksheetUse of form: The Child Care Authorization Worksheet is an agency tool to assist in the process of determining an accurate number of hours to authorize for a particular child care case. This form is not mandatory, nor should eligibility be solely denied for participants who fail to return this worksheet.Case Number FORMTEXT ?????Today’s Date FORMTEXT ?????Case Name FORMTEXT ?????Name – Authorization Worker FORMTEXT ?????SECTION ACircumstances for Authorization FORMCHECKBOX New authorizationBegin date: FORMTEXT ?????End date: FORMTEXT ????? FORMCHECKBOX ReviewBegin date: FORMTEXT ?????End date: FORMTEXT ????? FORMCHECKBOX ChangeEffective date: FORMTEXT ????? FORMCHECKBOX TerminationNo longer in approved activity effective: FORMTEXT ?????Child no longer attending effective: FORMTEXT ?????Other: FORMTEXT ?????Identify Case Type: FORMCHECKBOX Regular FORMCHECKBOX Foster care FORMCHECKBOX Non-court ordered Kinship Care FORMCHECKBOX W-2 / FSET FORMCHECKBOX Teen parent FORMCHECKBOX Court ordered Kinship Care FORMCHECKBOX Combination case (list details): FORMTEXT ?????SECTION BProvider Information (List multiple provider details in Section F.)Name – Provider FORMTEXT ?????Address – Provider (Street, City, State, Zip Code) FORMTEXT ?????Provider Number / Location FORMTEXT ?????Telephone Number – Provider FORMTEXT ?????Provider Hours of Operation FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No Is the provider related to any of the children?If “Yes”, which child(ren)? FORMTEXT ?????SECTION CApproved ActivityParent OneParent TwoName – Parent One FORMTEXT ?????Name – Parent Two FORMTEXT ?????Approved Activity (Check approved activity.)Approved Activity (Check approved activity.) FORMCHECKBOX Name – Employer FORMTEXT ????? FORMCHECKBOX Name – Employer FORMTEXT ????? FORMCHECKBOX High School FORMCHECKBOX Post Secondary Education FORMCHECKBOX Self Employed FORMCHECKBOX High School FORMCHECKBOX Post Secondary Education FORMCHECKBOX Self Employed FORMCHECKBOX W-2 / FSET (EP End Date: FORMTEXT ?????) FORMCHECKBOX W-2 / FSET (EP End Date: FORMTEXT ?????) FORMCHECKBOX Other – Specify: FORMTEXT ????? FORMCHECKBOX Other – Specify: FORMTEXT ?????Weekly Schedule of Approved Activity HoursWeekly Schedule of Approved Activity HoursBegin TimeEnd TimeDaily TotalBegin TimeEnd TimeDaily TotalSunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NOTE: If approved activity or schedule changes week to week, please identify a two week schedule in Section F.SECTION DChild(ren) InformationName – Child 1 FORMTEXT ?????Name – Child 2 FORMTEXT ?????Name – Child 3 FORMTEXT ?????Age FORMTEXT ?????Age FORMTEXT ?????Age FORMTEXT ?????Name – School Attending FORMTEXT ?????Name – School Attending FORMTEXT ?????Name – School Attending FORMTEXT ?????School Year: FORMCHECKBOX Traditional FORMCHECKBOX Year RoundSchool Year: FORMCHECKBOX Traditional FORMCHECKBOX Year RoundSchool Year: FORMCHECKBOX Traditional FORMCHECKBOX Year RoundSchool HoursCC HoursSchool HoursCC HoursSchool HoursCC HoursSunday FORMTEXT ????? FORMTEXT ?????Sunday FORMTEXT ????? FORMTEXT ?????Sunday FORMTEXT ????? FORMTEXT ?????Monday FORMTEXT ????? FORMTEXT ?????Monday FORMTEXT ????? FORMTEXT ?????Monday FORMTEXT ????? FORMTEXT ?????Tuesday FORMTEXT ????? FORMTEXT ?????Tuesday FORMTEXT ????? FORMTEXT ?????Tuesday FORMTEXT ????? FORMTEXT ?????Wednesday FORMTEXT ????? FORMTEXT ?????Wednesday FORMTEXT ????? FORMTEXT ?????Wednesday FORMTEXT ????? FORMTEXT ?????Thursday FORMTEXT ????? FORMTEXT ?????Thursday FORMTEXT ????? FORMTEXT ?????Thursday FORMTEXT ????? FORMTEXT ?????Friday FORMTEXT ????? FORMTEXT ?????Friday FORMTEXT ????? FORMTEXT ?????Friday FORMTEXT ????? FORMTEXT ?????Saturday FORMTEXT ????? FORMTEXT ?????Saturday FORMTEXT ????? FORMTEXT ?????Saturday FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this child need care before and / or after school? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this child need care before and / or after school? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this child need care before and / or after school? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this child need days off only? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this child need days off only? FORMCHECKBOX Yes FORMCHECKBOX NoDoes this child need days off only? FORMCHECKBOX Yes FORMCHECKBOX NoSpecial needs child? FORMCHECKBOX Yes FORMCHECKBOX NoSpecial needs child? FORMCHECKBOX Yes FORMCHECKBOX NoSpecial needs child?SECTION EShared Placement Information FORMCHECKBOX Yes FORMCHECKBOX NoIs there shared placement or joint custody of any of the children (court ordered or non-court ordered)?If “Yes”, complete Section E below with a detailed two week schedule as to when the child is in your care. (Further documentation may be requested to support the information identified below.)SundayMondayTuesdayWednesdayThursdayFridaySaturdayChild 1:Week One FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Week Two FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Child 2:Week One FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Week Two FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Child 3:Week One FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Week Two FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION FAdditional Comments FORMTEXT ?????SECTION GTravel TimeAllowable travel time per day or week: FORMTEXT ?????Notes: FORMTEXT ?????FOR AGENCY USE ONLYTotal Authorized Hours FORMTEXT ?????Co-Pay Code FORMTEXT ?????Authorization type: FORMCHECKBOX Enrollment FORMCHECKBOX Attendance FORMCHECKBOX CSAW education tracking completeRemaining education time –Post secondary education: FORMTEXT ?????Basic education: FORMTEXT ?????SIGNATURE – Person Completing FormDate Signed ................
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