Maryland Infants and Toddlers Program

Dear Parent/Guardian:

The Maryland State Department of Education requires us to verify that you received a copy of the "Maryland Infants and Toddlers Program" brochure. Please add the name of each child you have placed in the care of this provider in the field below. Complete and sign the statement a the bottom and submit it to us. We will print the form and retain it in our facility's files.

Child's Name(Required)

First Last

Child's Name

First Last

Child's Name

First Last

Child's Name

First Last

I have received a copy of the brochure entitled "Maryland Infants and Toddlers Program ." I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.(Required)

By checking this box and typing my name below, I am electronically signing my application.

Signature of Parent or Legal Guardian(Required)

First Middle Initial Last

Date(Required)