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If applicable please answer the following questions to assist us in determining the client s eligibility. Print Parent or Guardian s Name Eligibility for child care assistance based on a parent/guardian disability Choose one Is permanently disabled Is temporarily disabled until Exempt from work requirements due to age Licensed Physician s Signature Date RL/TW SR Disability Verification Form 092215 6800 N. Dale Mabry Hwy. SCHOOL READINESS PROGRAM DISABILITY VERIFICATION FORM To be completed...
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