Specialist. 129 Pleasant Street Concord NH 03301 Enter the name of the child. Provide the form to the Licensed Professional or Director for verification. RETENTION Form 2628 is retained in the eligibility record or at State Office.
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How to fill out the Form 2628 Nh online
Form 2628 Nh is a vital document used to verify a child's disability for eligibility in the Child Care Development Fund Scholarship. This guide outlines how to complete the form accurately online, ensuring that users, regardless of legal experience, can navigate the process with ease.
Follow the steps to complete the Form 2628 Nh online
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the section labeled 'To', provide the name, address, and telephone number of the licensed professional, special education director, or area agency director who will verify the child's disability.
- Fill in the 'Return To' section. For Employment Related Child Care, enter the name and address of the District Office Family Service Specialist. For Preventive and Protective Child Care, enter the address of DCYF Provider Relations at 129 Pleasant Street, Concord NH 03301.
- Enter the name of the child in the designated field.
- Consult with the licensed professional or director to confirm and obtain their verification of the child's disability. This may include providing treatment details and other necessary identifiers.
- Sign the form as the child's attending physician, physician’s assistant, advance practice registered nurse, or licensed mental health professional, ensuring to include the date.
- The parent or guardian must also sign the authorization section at the bottom of the form, which includes the date, indicating consent for the verification and information release.
- After completing all sections, review the form for accuracy. Finally, save your changes, download, print, or share the completed form as needed.
Complete your Form 2628 Nh online today to ensure timely processing and support for your child.
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