ETA-682 Child Care Certification

Date: 11/21/2006
SSN:

Child Care Certification
Name:

Page 1 of 1
Date of Birth:

Sex:

Student ID:
To be obtained from Applicant:
I, __________________________, have arranged for my child(ren) ______________________________(Names of children) to stay
with my __________________ (Relationship), ________________________ (Name of provider)
at ____________________________________________________________________________________________(Address)
during my enrollment in the Job Corps.

Signature of Applicant

Date

To be obtained from Provider:
I, __________________________, have agreed to take care of ________________________________(Names of children) in my
home at _______________________________________________________________________________ (Address)
while _________________________________________(Name of Applicant) is enrolled in Job Corps. I fully understand that this
enrollment may be as long as two years. The telephone number where I can be reached is ________________ .

Signature of Provider

Date

To be signed by the counselor:
Name of the Counselor's Office: ____________________________________________________________
In my opinion, the applicant's child(ren) will be adequately cared for by the person named above.

Signature of Counselor

OMB Expiration Date 02/28/07

Date

ETA 682 (REV 5/98)