Waiver Form
________________________________
__________________
________________ ______________
Child’s Name
Child’s Date of Birth
Phone Number
________________________________
__________________
________________ ______________
Address
City
State
________________________________
__________________
Adult 1 Name
Relationship to Child
________________________________
__________________
Adult 2 Name
Relationship to Child
Alt. Phone Number
Zip
_______________________________________________________
________________________________
Email
Previous Preschool/Birth-3 experience
_______________________________________________________
________________________________
Total # in Household/Annual Income
Center Selected
Reason for Requesting a Waiver ____ The MVCDC location nearest to my home does not offer transportation that my family needs ____ The MVCDC location nearest to my home does not offer the hours of operation my family needs ____ My family will not qualify for Publicly Funded Child Care because: __________________________________________________________ ____ My child is already enrolled in another program ____ Other: __________________________________________________________________________________________________________
_______________________________________________________
_______________________________
Parent/Guardian Signature
Date
Please Return To: Preschool Promise ATTN: 4C for Children – Preschool Promise Family Specialist 1000 N. Keowee St. Dayton, OH 45404 Or via email at [email protected]
OFFICE USE ONLY:
Date Submitted: ____________________
Approved _____ Denied _____ Date: ___________________
Signature of Preschool Promise Rep.: _________________________________________________________________________________
Rev. 3.21.2017
__________________
________________ ______________
Child’s Name
Child’s Date of Birth
Phone Number
________________________________
__________________
________________ ______________
Address
City
State
________________________________
__________________
Adult 1 Name
Relationship to Child
________________________________
__________________
Adult 2 Name
Relationship to Child
Alt. Phone Number
Zip
_______________________________________________________
________________________________
Previous Preschool/Birth-3 experience
_______________________________________________________
________________________________
Total # in Household/Annual Income
Center Selected
Reason for Requesting a Waiver ____ The MVCDC location nearest to my home does not offer transportation that my family needs ____ The MVCDC location nearest to my home does not offer the hours of operation my family needs ____ My family will not qualify for Publicly Funded Child Care because: __________________________________________________________ ____ My child is already enrolled in another program ____ Other: __________________________________________________________________________________________________________
_______________________________________________________
_______________________________
Parent/Guardian Signature
Date
Please Return To: Preschool Promise ATTN: 4C for Children – Preschool Promise Family Specialist 1000 N. Keowee St. Dayton, OH 45404 Or via email at [email protected]
OFFICE USE ONLY:
Date Submitted: ____________________
Approved _____ Denied _____ Date: ___________________
Signature of Preschool Promise Rep.: _________________________________________________________________________________
Rev. 3.21.2017
