_______________County Board of Education: _________________ Voucher
Parent/Guardian: ______________________________________________
Address: _____________________________________________________
Phone # ______________________________________________________
Child’s Age _____________ School _________________ Grade ________
Proof of Identification ____________________________________________
___________________________________________
The above identification must also be presented at the (name of vendor) for verification.
__________________________________________________________
Rules and regulations of the voucher:
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$ ______ (amount written out) voucher at the (Name of vendor).
Clothing voucher effective (date) and expires (date).
When arriving at (Name of vendor) take the voucher to the service desk.
Present the same proof of identification that was presented at the school and that is
also listed on the above application.
(Name of vendor) will compare your presented voucher and proof of identification with
the original voucher that was provided to (Name of vendor) by the school principal.
(Name of vendor) will then ask you to enjoy shopping for your child.
Voucher is only for clothing, school and personal hygiene supplies for the
school age child.
After shopping, take the items back to the service desk for check-out. (Name of
vendor) has the gift card at the desk.
Please spend as much of the gift card as possible because there will be NO balance.
(Name of vendor) will keep the sales receipt, the voucher forms, and gift card and
present them to the (County name) County Board of Education as proof of spending
for auditing purposes with the State of West Virginia.
I _______________________, principal at ______________________ School, discussed the
rules and regulations of the voucher with the parent/guardian.
I _______________________, parent/guardian am fully aware of the procedures to follow for
the voucher to be valid at the (Name of vendor).
I _______________________, a representative for (Name of vendor), verify proof of
identification and proper spending of the voucher.
I _______________________, parent/guardian, have enjoyed the shopping for my child.