CS5583 (2010/03)

Infant Care Incentive Parent Statement of Acknowledgement

I understand thatProgram Name

is required to share information with Alberta Children

and Youth Services in order to receive the Infant Care Incentive. The Infant Care Incentive pays a child care program $150 for each child between the ages of 0-18 months who attends the program for eight or more hours in a month.

The information that is shared with the Ministry includes the child's legal name, date of birth and hours of child care received each month. This information is submitted each month the child is eligible and is used to verify that the program is eligible to receive the Infant Care Incentive.

The personal information provided on this form is collected under the authority of the Government Organization Act and managed in accordance with the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection or use of this information, you can contact the child care subsidy program in the local Child and Family Services Authority.

The form will be maintained by the program for a minimum period of two years. The Ministry at any time can request the program to provide to the Ministry a copy of this signed agreement to verify that a parent signed this statement of acknowledgement.

Name of Child(ren)

Name of Parent/Guardian Signature of Parent/Guardian Date (mm/dd/yyyy)