Shasta County Local Child Care Planning Council Member In-Kind Contribution Form

Forms

Required

Shasta County Local Childcare Planning Council Member In-Kind Contribution Form

The information you provide on this form helps the Shasta LPC demonstrate in-kind contributions of members and guests to the CA Department of Social Services (CDSS).

NAMErequired

First Name

Last Name

ORGANIZATIONrequired

Ex: SCOE, First 5 Shasta

ATTENDEE TYPErequired

LPC Member

LPC Guest

Other

APPROXIMATE PAY RATE PER HOUR BEFORE TAXES OR DEDUCTIONSrequired

If you do not receive a salary, please estimate the value of your time. (Must contain only letters, numbers and spaces)

ATTENDINGrequired

In-person

Online

MEETINGS

MONTH ATTENDEDrequired

**ONLY SELECT MULTIPLE MEETINGS IF YOU NEED TO FILL OUT A MONTHLY IN-KIND FOR A PREVIOUS MEETING!**

MULTIPLE MEETINGS

Write which month here. Ex: August, November

TYPE OF SERVICErequired

TIME CONTRIBUTED (IN HOURS)required

Ex: 2 or 1.5 (Must contain only numbers)

ROUND TRIP MILEAGE TO ATTEND IN-PERSON MEETINGSrequired

(Must contain only numbers)

OTHER CONTRIBUTIONS (OPTIONAL)

ITEM

**ONLY FILL OUT THIS SECTION IF YOU'VE PROVIDED THE LPC WITH ITEMS!**

DATE YOU PROVIDED ITEMS:

Must contain a date in M/D/YYYY format

VALUE OF ITEMS:

Ex: $40.00 (Must contain only letters, numbers and spaces)

ACKNOWLEDGMENTrequired

By typing in your name in the signature field below you are signing this form electronically, and you agree that your electronic signature is the legal equivalent of your manual signature on this form.

SIGNATURErequired

(Must contain only letters and spaces)

Daterequired

Today's Date (Must contain a date in M/D/YYYY format)

Thank you!

Your participation helps us strengthen our partnership with the community on behalf of the families we serve.

In This Section

Forms

Links & Resources