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CS-274W REVERSE Indicate the weekly schedule s of child care services for the child ren listed below Child s Name CHILD S NAME MONTH DAY YEAR To From Date of Birth Date Care Began Weekly Schedule Monday Tuesday Wednesday Thursday Friday Saturday Sunday OFFICE USE ONLY Total Hours per Week ACS Child Care Rate I acknowledge that receiving payment from the City of New York for child care services provided does not make me an employee of the City of New York. You cannot be required to disclose your ...

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