OU-HCOM Day Care Provider Certification Form
Name of Day Care Provider:
Address:
Phone:
This section to be completed by day care provider.  Day care provider must attach a schedule of fees charged to parent(s).
This is to certify that the children listed below attend this day care program:
Name(s)						Age(s)
□Daily	□Full	□Half	□Other-- Please Specify:
Cost per hour:				Time Period of Enrollment:
Cost per week:				□Month		□Year
Cost per month:				□Month		□Year
I certify that the above statements are true and accurate to the best of my knowledge.
Signature of Day Care Provider						Date
The following section to be completed by parent/guardian.
The child's/children's other parent is not available to provide supervision because:
□Full-time student				□Employed full-time (attach employer statement)
□Other--Please explain:
I certify that the above statements are true and accurate to the best of my knowledge.
Signature of Parent						Date
Please note that the appeals for projected day care costs may be subjected to verification at the end of the academic year.  Audit findings that differ from the appeal may result in the student having to return funds.  Your appeal amount will be limited to the following amounts:  $415 per month for full-time day care, for ages birth-3 years and $363 per month for 2-5 years old.