I, certify that I am requesting reimbursement for child care assistance for the following semester.

Name: 
Please choose Semester:
I further agree that the CHILD CARE PROVIDER was selected by me, and should any problems arise concerning the well-being of my children while under the provider’s care, Adult Services will not be held responsible.

Your child care check will be mailed to the address you provide below. If you have a special circumstance, such as trouble with mail delivery or a protected address, you can make arrangements to pick up your check from Adult Services. If you want to arrange to pick up your check, you must discuss that with a staff member each time you complete this form.

Please note: There could be a delay in receiving your check if you choose to pick up your check.


Street Address:
City, State and Zip:
Email:
Student ID: