ECC REQUEST FORM - New Schedule, Schedule Change & Ending Child Care Form

ECC REQUEST FORM - New Schedule, Schedule Change, Transfer Locations & Ending Care

* Current families can complete this form by the 15th of the month and billing changes will take effect on the 1st of the following month. * New families can also request a starting schedule using this form. We will email you to confirm after we have reviewed availability. * See our tuition and enrollment policies for details.
Child's Name*

First Name Last Name
Child's Age*
Will your family be paying out of pocket or with DHS/State Assisted Pay?*

Out of pocketDHS/State Assisted Pay (already approved)DHS/State Assisted Pay (DHS application pending approval)Unsure
Request Type: All children listed above are requesting the following changes effective in the 1st of the following month:*

Schedule change for current family (must complete the schedule question)New or returning student (must complete schedule and location questions)Change location/transfer request (must complete location and schedule questions)Ending child care services. Last day will be at the end of this month.
Primary Payer/Parent/Guardian - this must be the person completing this form*

First Name Last Name
Phone Number

Area Code Phone Number
Email (we will contact you via email)*
example@example.com
Change Location/Transfer Requests

Only complete this section if you are requesting a transfer to a new location OR if you are a new family. If so to either, you must ALSO complete the schedule question below.
What location would you like to transfer to? New families: what program are you requesting to enroll into?
Schedule Requests

Please only complete this section if you are requesting a NEW or CHANGED schedule or location. Our office will review availability and email you with confirmation or follow-up questions. IMPORTANT! **Weekly schedules must be the same days throughout the month.

	Drop-Off Time	Pick-Up Time
Monday
Tuesday
Wednesday
Thursday
Friday

Ending Care Exit Survey

If you are ending child care services, do you have any feedback that you'd like to share about our programs? Please also list the name of the program.
Program name and feedback:
Schedule Change/Ending Care Policies

Signers/primary payers must agree to the following. - I understand that it is my responsibility as the primary payer to make timely request to ensure contractual service agreement terms are met so programs can prepare accordingly. - I understand that, if the ECC administrative office does not receive this form by the 15th of the month, no billing or schedule adjustments will be made for the following month. - I understand that ECC does not pro-rate the last month of care and I will be charged until the last day of the month even if my child does not attend. DHS/state pay may NOT cover the entire month's charges if I fail to ensure that my child(ren) attend the required minimum hours for my rate bracket throughout the entire month (and less than the maximum). This means I could be charged out of pocket, even if I have a $0 copay. It is my responsibility to consult DHS Direct Pay Unit to ensure my schedule will meet my billing needs. - I understand that these enrollment and tuition policies can be found on the ECC website (creativecareeugene.org) and are also available upon request. ********* ECC administrative office can be reached at creativecare.eugene@gmail.com
"I have read and understood the above" Signature of Primary Payer*

Clear
Today's Date*

MonthDay Year
Should be Empty:

ECC REQUEST FORM - New Schedule, Schedule Change, Transfer Locations & Ending Care

Change Location/Transfer Requests

Schedule Requests

Ending Care Exit Survey

Schedule Change/Ending Care Policies