Scribd
Upload
29 views

End of Placement

Uploaded by

esminna03
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
29 views

End of Placement

Uploaded by

esminna03
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

FID # ______________

End of Child Care Placement Form


If you need to end a placement or to change providers prior to the scheduled end date of a voucher, please do
the following:
 Provide two weeks notice in writing indicating the child(ren)’s expected last day of attendance.
 All outstanding fees (if any) must be paid to the current provider before a new voucher will be issued.
 Complete and submit this form along with a completed Confirmation of Provider form to verify a start
date for a new provider.

Date of Notice: 4/31/24


_______________
Parent/Guardian: Hetshepsep Getchell
________________________________________ 857-707-0798
Phone # ____________________
(First name) (Last name)

Child #1: Catalina .R. Torres


____________________________ Child #2: ____________________________
Child #3: ____________________________ Child #4: ____________________________

Program/Provider Name: Esminna Baez


________________________________________
37 joyce hayes way, South Boston.
Address: ________________________________________ 857 268 04 19
Phone# __________________
________________________________________

8/9/24
The child(ren)’s last day of care with my program will be on (date) ______________________.
The last day I will be billing for care for this child(ren) is on (date)______________________.
Does the parent owe any outstanding fees: ___ Yes ___ No
(only fees assessed as part of the voucher agreement—do not include any
other type of fees owed to your program)

If yes, how much does the parent owe? $________________


If outstanding fees are owed, a Family Services Specialist will contact you to confirm receipt of payment before a new voucher will be issued.

✔
Please indicate the reason ___ Owes fees ___ Voluntary ___ Custody change ___ Changing providers
for end of placement: Other:____________________________________

_________________________________________________ ___________________
Parent Signature Date
5/3/24
_________________________________________________ ___________________
Provider Signature Date

105 Chauncy Street, Boston, MA02111 P: 617-542-5437 (KIDS) F: 617-292-4629

You might also like