ETA 682 Child Care Certification

ETA FORM 682

OMB Control No. 1205-0025

Expiration Date: xx/xx/xxxx

U.S. Department Labor

Employment and Training Administration

Child Care Certification

_________________________________________________________________________________________________________

1. To be obtained from applicant:

I, _______________________________, have arranged for my child(ren), ________________________________

________________________________________________________, (Names of child or children) to stay with my

_________________________ (Mother, etc.) ________________________________________ (Name of Provider)

at _________________________________________________ (Address) during my enrollment in the Job Corps.

_____________________________________________________________________________________________

Signature of Applicant Date

2. To be obtained from provider:

I, ______________________________, have agreed to care for ________________________________________

_____________________________________________, (Names of child or children) in my home

at ______________________________________________________________ (Address) while my (daughter, etc.)

is enrolled in Job Corps. I fully understand that this enrollment may be as long as two years. The telephone number

where I may be reached is ( ) __________________.

_____________________________________________________________________________________________

Signature of Care Provider Date

3. To be signed by the Admissions Counselor:

In my opinion, the applicant’s child(ren) will be adequately cared for by the person named above.

_____________________________________________________________________________________________

Signature of Admissions Counselor Date

_____________________________________________________________________________________________

Privacy Act Notice:

All request for personal information about students must be treated as requests under the Freedom of Information Act and the Privacy Act of 1974, and handled pursuant 29 CFR Parts 70 and 70a and 45 CFR Parts 160 and 164.

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0025). Please do not submit completed forms to this address.

CHILD CARE CERTIFICATION

1. Purpose. To verify and document that an applicant with dependent children has established suitable arrangements for the care of any dependent children for the proposed period of enrollment in Job Corps.

2. Originator. Job Corps Admissions Counselor.

3. Frequency. For each applicant with dependent children.

4. Distribution. One copy of the completed ETA 6-82 is retained in the applicant’s file in all applicable cases.

5. General Instructions. Information asked for is self-explanatory. The applicant completes, signs and dates Section 1; the care provider completes, signs and dates Section 2; and the Job Corps Admissions Counselor signs and dates Section 3.

6. Disposition. To be kept in applicant’s folder.

ETA Form 682 (Rev. 3/31/2014)