Get FCPS SS/SE-252 2010-2024

Full-time before and/or after school child care is needed for student transfer consideration. Be sure to fill in all sections or enter N/A in sections not applicable. AFFIDAVIT FOR STUDENT TRANSFER CHILD CARE REQUESTS ELEMENTARY ONLY SCHOOL YEAR This form is required documentation for all child care student transfer requests K-6 only Forms SS/SE-222 and SS/SE-223. The child care provider must be located within the requested school boundaries and parents or guardians must show hardship in obtaining child care in the base school boundaries. FCPS staff will verify information provided* I. THIS SECTION TO BE COMPLETED BY THE ORGANIZATION OR INDIVIDUAL PROVIDING CHILD CARE Current Grade Level Relationship to Child Name of Person or Organization Address City State Zip Phone Number I hereby certify that I we have agreed to provide regular child care services for Name of Child as follows From a*m* to p*m* on the following week days Remarks Signed Name of Individual Title If Applicable Date Use this section to document attempts made to secure child care in the base school boundaries. Attach additional documentation if necessary. 1. Provider Name Reason Not Used III. SECTION TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN I understand that providing false or otherwise untrue information for any of the items above could result in a criminal charge of perjury being brought against me. I certify that if any of the conditions indicated in this document should change during this school year I we will notify the school administration within 10 business days. Name of Student s Father or Guardian Signature NOTE ONLY PARENT OR GUARDIAN SIGNATURE MUST BE NOTARIZED Subscribed and sworn before me this day of 20 State County My commission expires Witness my hand in official seal Notary Public Return This Form and Application to the Base School Registration Number SS/SE-252 3/10. FCPS staff will verify information provided* I. THIS SECTION TO BE COMPLETED BY THE ORGANIZATION OR INDIVIDUAL PROVIDING CHILD CARE Current Grade Level Relationship to Child Name of Person or Organization Address City State Zip Phone Number I hereby certify that I we have agreed to provide regular child care services for Name of Child as follows From a*m* to p*m* on the following week days Remarks Signed Name of Individual Title If Applicable Date Use this section to document attempts made to secure child care in the base school boundaries. Attach additional documentation if necessary. 1. Provider Name Reason Not Used III. SECTION TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN I understand that providing false or otherwise untrue information for any of the items above could result in a criminal charge of perjury being brought against me. Attach additional documentation if necessary. 1. Provider Name Reason Not Used III. SECTION TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN I understand that providing false or otherwise untrue information for any of the items above could result in a criminal charge of perjury being brought against me. I certify that if any of the conditions indicated in this document should change during this school year I we will notify the school administration within 10 business days. .