Request For CCAA Cards

Mailing Address

Residence Address (If Different)

Contact Information:

Please Check One or Both

By authorizing the additional card holders listed above, I agree to the following:

I also understand that Child Care Services will determine grounds for potential fraud if I or the secondary cardholder:

Failure to use your attendance card may result in a termination by your provider and will count as an absence to be included in the 65 day absence count.

By typing my name below I verify that I am currently receiving child care services and I acknowledge that I have read and agree to the responsibilities of being a CCAA Card Holder and I will instruct additional CCAA cardholders of their responsibilities.