Early Childhood Community Center Waitlist Form
Please note: Submitting this form does not guarantee a spot at CCC's Early Care & Education Center. CCC will use the information on this contact form to contact parents & caregivers regarding the waitlist status and potential enrollment opportunities. The Early Childhood Care Center serves children 0-5, emphasizing children aged 0-18 months.
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Which space would you like to be added to the wait list for?
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CCC Maine Street (346 Maine Street)
CCC Southwest (4640 W 27th St)
First Available
Child's Name
*
First Name
Last Name
Child's Birthdate or due date
*
Child's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have another child on the wait list for CCC?
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Yes
No
If the answer to the above question was "Yes" please list the names and ages of other children you have on the waiting list.
Child Care Information
Desired Start Date
*
Our child care center offers the following schedule. Please indicate which session you would like to enroll your child. If you select multiple days, please note which days you would like care.
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Traditional Care (8-10 hrs. a day). Infants through 2-year-olds
Monday - Friday between 6:30 AM to 5:30 PM [Full-time]
Multiple days a week. Infants through 2-year-olds. Regularly scheduled 2-days or 3 days [Part – time]
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekend Care. Hours between Friday 5:30 PM – Monday 6:30
Evening/Overnight Care (8-12 hours). between 5:30 PM – 6:30 AM
Drop In / Occasional Care – by Reservation
My schedule does not fit the hours of the programs listed, would like to chat about my family needs.
Parent/Guardian #1 Name:
*
First Name
Last Name
Parent/Guardian #1 Relationship to Child
*
Parent/Guardian #1 Email
*
example@example.com
Parent/Guardian #1 Main Phone
*
Please enter a valid phone number.
Parent/Guardian #1 Alternative Phone
Please enter a valid phone number.
Parent/Guardian #1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian #2 Name
First Name
Last Name
Parent/Guardian #2 Relationship to Child
Parent/Guardian #2 Email
example@example.com
Parent/Guardian #2 Main Phone
Please enter a valid phone number.
Parent/Guardian #2 Alternative Phone
Please enter a valid phone number.
Parent/Guardian #2 Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tell us about your family!
What is the best way to reach you?
*
Text
Email
Phone Call
Other
How did you hear about CCC child care?
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Email
Flyers/Handouts
Press Release/Newspaper
Community Children’s Family Resource Center Activities
Community Event
Parenting Class
Family Support Group
Facebook
Instagram
Referral
Other
If you answered "Referral" to the previous question, who referred you?
We'd love to thank them!
What child care arrangements are you considering?
*
Family Child Care Home
Nanny or In-Home Provider
Family, Neighbors, Friends
Other Child Care Centers
Other
Is your child currently enrolled in another child care program?
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Yes
No
If you answered "Yes" to the previous question, please share the name of the program.
Anything else you want to tell us about your child and/or family?
If you have concerns or questions about caring for your child or parenting challenges don't hesitate to call 785-260-8184. We are here to offer services and support that wrap around the entire family.
Would you like to receive short, regular updates from Community Children's Center?
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Yes
No
Authorization
I understand that submitting this form does not guarantee a spot for my child at CCC’s Early Care & Education Center. I authorize CCC to contact me using the provided contact information regarding the waitlist status and potential enrollment opportunities.
Parent/Guardian Signature
*
Submit
Submit
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