State of Illinois
Department of Human Services
IDHS CHILD CARE ASSISTANCE PROGRAM
SIGN-IN / SIGN-OUT LOG
Provider Name:
Provider Location:
Service Period:
Month:
Year:
Date:
Parent Please Read: By signing this log, I attest that this is an accurate record of the hours and day of attendance. Each individual child must be signed in and out.
Child Name
Parent/Guardian Name
Signature
Time In
Signature:
Time Out
I attest that this is an accurate reflection of the hours and day of attendance for the above listed children.
Provider Name:
Provider Signature:
* I no longer care for:
as of (enter date):
IL 444-1902 (N-06-16) IDHS Child Care Assistance Program Sign-In/Sign-Out Log
Printed by Authority of the State of Illinois
38,000 Copies
PO#16-1868
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