From: (Names of parents or guardians)

Address:

To: (Organization that administers the tuition assistance subsidy program)

Address:

Subject: Tuition Assistance Award Weekly Amount of $_________________ for (insert name of child) to attend the (insert name and address of child care program).

I/We agree to accept the tuition assistance award of $_______________ per week. We understand that the award becomes effective (insert date) and remains in effect until September 30, 2000 or the date when our child is no longer enrolled in the child care program named in this agreement, whichever occurs first. I/We agree to notify (name of Organization) if and when our child is no longer enrolled at (insert name of child care program).

I/We understand we will be billed by the (insert name of child care provider) for the prevailing tuition rate less the tuition assistance award. If the tuition is increased during the award period, we understand the amount of the award does not change.

Parent(s) Signature(s): _______________________________

Date: _______________

__________________________________________________

Date: ______________

To activate your award, return this form to:

(Insert name and address of organization administering the program)

Your award will not become effective unless this form is returned to the organization named above. It verifies that your child will be enrolled in the program you indicated on your application form and you accept the decision to reduce your tuition costs by the amount of the award stated above.

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