Education Schedule Verification Form - Child Care Information Services Of Berks County, Pennsylvania

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EDUCATION SCHEDULE VERIFICATION
THE SHADED AREAS MUST BE COMPLETED BY AN AUTHORIZED SCHOOL REPRESENTATIVE ONLY
Name of the School District:
____________________________________________________________________________________________
Name of the school attending:
__________________________________________________________________________________________
Grade in school:
First day of enrollment:
_____________________
_____________________
First day of enrollment for the current year:
Last day of enrollment for the current year:
________________
________________
Attending school:
Part-time
Full Time
Anticipated completion/graduation date:
________________________________________________
Type of program:
Elementary
Middle School
High School
GED Program
Current Schedule of Classes:
If class schedule is consistent, complete Week One only.
If class schedule varies, complete all four weeks.
WEEK ONE:
WEEK TWO:
Date : ____________________
Date : ____________________
Monday
Monday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Tuesday
Tuesday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Wednesday
Wednesday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Thursday
Thursday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Friday
Friday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Saturday
Saturday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Sunday
Sunday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
WEEK THREE:
WEEK FOUR:
Date : ____________________
Date : ____________________
Monday
Monday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Tuesday
Tuesday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Wednesday
Wednesday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Thursday
Thursday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Friday
Friday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Saturday
Saturday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
Sunday
Sunday
from ________ AM / PM to ________ AM / PM
from ________ AM / PM to ________ AM / PM
SCHOOL SEAL OR STAMP:
CD 924 7/07

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