FAMILIES

Provider Transfer Request — Parent/Guardian

Parent-completed portion of the ELCHC Provider Transfer Form (Rev. 2/8/18).

A parent may not transfer school readiness program services to another provider until the current provider has submitted documentation stating that the parent has satisfactorily fulfilled the copayment obligation. Complete this form to request a transfer; your current provider will submit their portion separately.

Section I — Parent/Guardian Information

Parent/Guardian Name(Required)
Address
Child(ren) to be Transferred
Name of Child
Child's Date of Birth
 

Section II — New Provider

Address