MyForms24/7

Staff Signature Page


Facility Name:
Please type the Facility name " FUNSHINE LICENSED CHILDCARE " in the box above. The name is there for reference but will need to be typed by you to complete the form.
License #:  

Employee Name:
Date of Birth:
Employee Phone Number:
PDIS User Name:  
Employee Address:  
Date of Hire:
Position/Classroom:  

Emergency Contact Name:  
Emergency Contact Address:  
Emergency Contact Phone Number:  
Emergency Contact Relationship:  

PERJURY STATEMENT:
"Any applicant who knowingly or willfully makes a false statement of any material fact or thing in the application is guilty of perjury in the second degree as defined in section 18-8-503, C.R.S., and upon conviction thereof, shall be punished accordingly.

POLICY STATEMENT:
I have read and understand the policies and procedures for this facility.

RULES AND REGULATIONS:
I verify that I have read and been trained on the rules and regulations governing my child care program including medication administration procedures.

EMERGENCY TRAINING:
I verify that I have been trained in emergency procedures for this facility.

 

Leave this empty:

Signature arrow sign here

Signed by Christiane Skeldum
Signed On: March 29, 2024


Signature Certificate
Document name: Staff Signature Page
lock iconUnique Document ID: 2eec607fabc8033dc7545663c1f6edd2b5aca5ad
Timestamp Audit
March 8, 2024 9:30 am MDTStaff Signature Page Uploaded by Christiane Skeldum - clester62@gmail.com IP 184.99.46.212