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M I I ~ I I" CC-218-PD (7-14) ARIZONA DEPARTMENT OF ECONOMIC SECURITY SIGN-IN/SIGN-OUT RECORD PENALTY WARNING: By signing this document the parent, guardian, or other authorized person verifies, under penalty of perjury, that the times recorded are the actual times the child was in attendance. S i g n - i n / S i g n - o u t

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S h e e t PENALTY WARNING: The submission of billing claim forms for the child named on this record constitutes verification by the Provider, under penalty of perjury, that this document is a true and accurate record of signatures, dates, and time of service.