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DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education CCWS Child Care Authorization Worksheet Use 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 Today’s Date Case Name Name – Authorization Worker SECTION A Circumstances for Authorization New authorization Begin date: End date: Review Begin date: End date: Change Effective date: No longer in approved activity effective: Child no longer attending effective: Termination Other: Regular Foster care Non-court ordered Kinship Care W-2 / FSET Teen parent Court ordered Kinship Care Identify Case Type: Combination case (list details): SECTION B Provider Information (List multiple provider details in Section Name – Provider Address – Provider (Street, City, State, Zip Code) Provider Number / Location Telephone Number – Provider Provider Hours of Operation Yes No Is the provider related to any of the children? If “Yes”, which child(ren)? SECTION C Approved Activity Parent One Parent Two Name – Parent One Name – Parent Two Approved Activity (Check approved activity.) Approved Activity (Check approved activity.) Name – Employer Name – Employer High School Post Secondary Education Self Employed High School Post Secondary Education Self Employed W-2 / FSET (EP End Date: ) W-2 / FSET (EP End Date: ) Other – Specify: Other – Specify: Weekly Schedule of Approved Activity Hours Weekly Schedule of Approved Activity Hours Begin Time End Time Daily Total Begin Time End Time Daily Total Sunday Sunday Monday Monday Tuesday Tuesday Wednesday Wednesday Thursday Thursday Friday Friday Saturday Saturday NOTE: If approved activity or schedule changes week to week, please identify a two week schedule in Section F. DCF-F-2742-E 11/2011) ---PAGE BREAK--- SECTION D Child(ren) Information Name – Child 1 Name – Child 2 Name – Child 3 Age Age Age Name – School Attending Name – School Attending Name – School Attending School Year: Traditional Year Round School Year: Traditional Year Round School Year: Traditional Year Round School Hours CC Hours School Hours CC Hours School Hours CC Hours Sunday Sunday Sunday Monday Monday Monday Tuesday Tuesday Tuesday Wednesday Wednesday Wednesday Thursday Thursday Thursday Friday Friday Friday Saturday Saturday Saturday Yes No Does this child need care before and / or after school? Yes No Does this child need care before and / or after school? Yes No Does this child need care before and / or after school? Yes No Does this child need days off only? Yes No Does this child need days off only? Yes No Does this child need days off only? Yes No Special needs child? Yes No Special needs child? Yes No Special needs child? SECTION E Shared Placement Information Yes No Is 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.) Sunday Monday Tuesday Wednesday Thursday Friday Saturday Child 1: Week One Week Two Child 2: Week One Week Two Child 3: Week One Week Two SECTION F Additional Comments 2 ---PAGE BREAK--- SECTION G Travel Time Allowable travel time per day or week: Notes: FOR AGENCY USE ONLY Total Authorized Hours Co-Pay Code Authorization type: Enrollment Attendance CSAW education tracking complete Remaining education time – Post secondary education: Basic education: SIGNATURE – Person Completing Form Date Signed 3