ELRC 18 Enrollment Transfer Request

IMPORTANT NOTES:

This form must be completed by the parent/caretaker or provider.
This form is only for children currently funded by ELRC 18.
- If the subsidy case has closed, contact family services to have the case reopened.
- This form is not a substitute for applying for subsidized child care funding.
- If subsidy funding comes from a different ELRC Region, you must contact that Region directly with your request.
Any weekly family copayment must be paid in full THROUGH THE LAST DAY OF CARE before submitting a transfer request.
Please notify current provider directly of the child's last day of care.
As long as children are enrolled with/transferring to the same provider, you can include them all on one form. You must submit a separate form for each child if different providers are involved though.

This form is NOT a confirmation of enrollment. Once ELRC receives your request, staff will confirm with the parent, the current provider and new provider and will notify you directly once the transfer has been approved.

If you have questions or need assistance completing this form, please call ELRC 18 at (610) 480-3190 or send an email to ELRC18family@phmc.org.

Parent/Caretaker Name*

First NameLast Name

Parent/caretaker date of birth*

Date

ELRC Case Record Number

Your Case Record Number can be found on most correspondences from ELRC. If you cannot find it, please contact ELRC 18 for assistance.

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

List each child involved with this transfer request:*

Provider name*

Is copay paid through child's last day of care?*

YesNo (Do not submit this form until the copayment is paid THROUGH THE LAST DAY OF CARE!)N/A - There is no copayment for this enrollment.

Provider Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Provider's PELICAN Number (if known)

Phone Number*

Please enter a valid phone number.

Provider contact name

First NameLast Name

Is this provider related to the child(ren)*

YesNo

How is the provider related to the child(ren)

OPTIONAL: If you would like the new provider to receive a copy of this request, please enter their email address:

example@example.com

Signature*

ELRC 18 Enrollment Transfer Request

Parent/Caretaker Information

Child(ren) Information

Current Provider Information

New Provider Information