Pathways LA

Digital Attendance Submission Record

Claim ID 412138 CAPP 0011300412138

Provider Name: BERTHA CECILIA CHILEL DE GAMBOA (203016) Month/Year: March 2023
Type/Vendor ID: Exp-In-Non-Rel / 203121 Child Name: LEANDER K GALEANO AGUILAR
Address: 835 1/2 West 41st Street Parent Name: CARMEN AGUILAR (41995)
City: Los Angeles, CA 90037-2299 Case Specialist: Stephanie Gutierrez
Phone: (323) 723-8081 Schedule Type: Set Variable Combo
Childcare attendance to be completed daily with exact times. Write reasons for absence, variance in schedule, or any days of provider non-operation, in the “Notes” section.
El registro de asistencia se debe completar diariamente con horarios exactos. Escriba la razón de cualquier ausencia, variación en el horario, o días no operativos del proveedor, en la
sección de "Notas."
Date Day Time In Time Out Time In Time Out Time In Time Out Total Hours Absent Reason
01 Mié 07:00 AM 06:00 PM 11.00
02 Jue 07:00 AM 06:00 PM 11.00
03 Vie 07:00 AM 06:00 PM 11.00
04 Sáb
05 Dom
06 Lun 07:00 AM 06:00 PM 11.00
07 Mar 07:00 AM 06:00 PM 11.00
08 Mié 07:00 AM 06:00 PM 11.00
09 Jue 07:00 AM 06:00 PM 11.00
10 Vie 07:00 AM 06:00 PM 11.00
11 Sáb
12 Dom
13 Lun 07:00 AM 06:00 PM 11.00
14 Mar 07:00 AM 06:00 PM 11.00
15 Mié 07:00 AM 06:00 PM 11.00
16 Jue 07:00 AM 06:00 PM 11.00
17 Vie 07:00 AM 06:00 PM 11.00
18 Sáb
19 Dom
20 Lun 07:00 AM 06:00 PM 11.00
21 Mar 07:00 AM 06:00 PM 11.00
22 Mié 07:00 AM 06:00 PM 11.00
23 Jue 07:00 AM 06:00 PM 11.00
24 Vie 07:00 AM 06:00 PM 11.00
25 Sáb
26 Dom
27 Lun 07:00 AM 06:00 PM 11.00
28 Mar 07:00 AM 06:00 PM 11.00
29 Mié 07:00 AM 06:00 PM 11.00
30 Jue 07:00 AM 06:00 PM 11.00
31 Vie 07:00 AM 06:00 PM 11.00
Total Hours
Total Days Total Absence
(Total/Normal/EW)
Family Fee $ 0.00 WK 1 3 33.00 / 33.00 / 0.00 0
Collected Family Fee: $ WK 2 5 55.00 / 55.00 / 0.00 0
Invoice Amount: $ WK 3 5 55.00 / 55.00 / 0.00 0
Month Total Day: 23 WK 4 5 55.00 / 55.00 / 0.00 0
Month Total Hours: WK 5 5 55.00 / 55.00 / 0.00 0
253.00 / 253.00 / 0.00
(Total/Normal/EW) WK 6 0 0.00 / 0.00 / 0.00 0
Comment:
ATTENDANCE CERTIFICATION
I certify under penalty of perjury that student care services as recorded on this attendance record have been provided.

Parent Full Signature: Date:

Provider Full Signature: Date:

Bridge Program ONLY: All services provided shall be invoiced within 60 days of the month for which services were rendered.

[Digital Attendance Record] Pathways LA • 3325 Wilshire Blvd Suite 1100 • Los Angeles, CA 90010-1703 • (213) 427-2700 •
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