This form is for Early Learning Program providers who have agreements with Workforce Solutions for North Central Texas to report
5-day consecutive absences of children enrolled in the TWC scholarship program. Do not submit this form if the child has been absent for fewer than 5 consecutive days. 

Select County from the drop-down menu first to filter the list of providers. Contact information will be populated with data on file; make any changes to name or phone number before submitting the form.

* indicates required fields

County*

Select county Collin Cooke Dallas Denton Ellis Erath Fannin Grayson Hamilton Henderson Hill Hood Hunt Johnson Kaufman Navarro Palo Pinto Parker Rockwall Somervell Tarrant Van Zandt Wise Wood Young

Provider Name* (CCS Provider Number)

Select provider name

Authorized Representative Name*
Phone Number*

Complete the form below for all children with 5 consecutive absences.

Child 1	Child Name* Parent/Caregiver Name* Date of First Absence* Date of Last Absence* CPS Case*  Yes  No Reason for Absence* Select New start has not attended Sick Court ordered Chronic illness/disability Unknown
Child 2	Child Name Parent/Caregiver Name Date of First Absence Date of Last Absence CPS Case  Yes  No Reason for Absence Select New start has not attended Sick Court ordered Chronic illness/disability Unknown
Child 3	Child Name Parent/Caregiver Name Date of First Absence Date of Last Absence CPS Case  Yes  No Reason for Absence Select New start has not attended Sick Court ordered Chronic illness/disability Unknown
Child 4	Child Name Parent/Caregiver Name Date of First Absence Date of Last Absence CPS Case  Yes  No Reason for Absence Select New start has not attended Sick Court ordered Chronic illness/disability Unknown
Child 5	Child Name Parent/Caregiver Name Date of First Absence Date of Last Absence CPS Case  Yes  No Reason for Absence Select New start has not attended Sick Court ordered Chronic illness/disability Unknown