Warren County Empowerment Board

4 R KIDS ECI Board

2011-2012

Tuition Assistance Program

Please complete this monthly form and any requested documentation by the 20th of each month:

ISU Extension & Outreach - Warren County Email:

909 E. Second Ave., Suite E Fax: 515-961-6017

Indianola, IA 50125

Name of Preschool: ______

Preschool Mailing Address: ______

Month of Service: ______Year of Service: ______

Child’s Name / Monthly Approved Cost / Attendance is in accordance with contract?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Total Voucher Amount: ______

Representative Signature: ______

Please attach sheets for month of service requested. Include explanation for any day missed by assisted child as to why (illness, appointment, out of town, etc.) the child was unable to attend.

Thank you!

4 R Kids ECI Board