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Revised 2-11-21 Early Leaming Coalition 2 of Palm Beach County Readly to Legra Ready for L )t A 7 { 23 CHILD CARE PROVIDER TRANSFER/ADDING A 2"> PROVIDER FORM Parent/Guardian must submit this form 10 days in advance of the child's start date to allow for processing and payment. Transfers are processed when fees are verified as paid. Form will need to be uploaded to your family portal account. PARENT/GUARDIAN NAME —Darinesha white Phone number 561-216-9323 Email Address: [email protected] ; (certificate will be sent electronically) chiLp: ADream Mickens - 5 SoA03 4. (o020 CHILD: & _D.0.B. / el CHILD: L D OB, / / CHILD: . D.0.B. / i TRANSFER ONLY: TRANSFERRING FRom:Dameka Coleman familydaycare ~~~ ExiTDATE: Ji TRANSFERRING TO: Iree house leamning center MZERO BALANCE: TO BE COMPLETED BY THE PROVIDER TRANSFERRED FROM (gmt signed by the provider, attach documentation confirming payment of Parent Fees) NO PARENT FEE IS ASSESSED The parent listed has paid all School Readiness co-payments and receipts were given to parent. Section 1002.84(8), F.S. requires providers to collect the parent copayment (fee). Providers who choose not to collect assessed copays will be violating statute and subject to corrective actions that may include termination of their school readiness contract. Statute and rule apply only to parent copayments and does not include additional fees that a provider may charge the parent. | understand that the School Readiness child listed above may be transferred to another pr '%rwith%nfOCfE&iEn/;;OaVkF)'i i f7 /_g/jlflzflgg SIGNATURE OF CHILD CARE PROGRAM DIRECTOR/DESIGNEE DATE ADDING A 2"° PROVIDER ONLYPelect all that apply: [ Inon-scHooL DAYS AFTERCARE |_|WINTER BREAK [] sprING BREAK [lsummer _ PHONE5/1-692-9789 P/ AL L new proviner: Dameka Coleman END DATE (if applicable): PARENT SIGNATURE: FOR ELC STAFF ONLY A e G L e B S SR B e s / / SIGNATURE OF THE EL STAFF VERIFYING THAT THE INFORMATION DATE Florida O T (Goigrens gi>ke" ~am 717 [earni: Services Council u @ CLARN EARIY LEARW FOR L5 Meaithy. Sate. Stromg. If you have any questions, please contact our Call Center at 561- 514-3300
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