Drop-in Childcare Services Intake Form

Drop-in Childcare Services Intake Form
Parent/Guardian Name*

First NameLast Name
Student ID Number*
Parent/Guardian Email*
example@example.com
Parent/Guardian Contact Number*

Area CodePhone Number
This number will be used to contact you while child(ren) are in the drop-in center.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Childcare services can be provided during your classes or up to 90 minutes per day for study sessions or while attending other resources on campus.
Which ICC Campus do you need childcare services*

Rutherford Campus (Health and Public Services, 15)Polk Campus
What days will you need drop-in childcare services (check all that apply)*

MondayTuesdayWednesdayThursdayFriday
Times you will be needing drop-in childcare services.*
Schedules will be verified.
Configurable list*
Please read the following carefully and check each box to indicate that you understand and agree to the following conditions.*

I certify that I have an emergency childcare need resulting from the effects of Hurricane Helene.I need to use this service to attend classes, tutoring, and other school related services between October 21 and December 18, 2024I understand that no food or supplies will be provided, and I will leave any supplies my child needs at drop-offI understand that the center will not administer any medication. If my child requires medication, I will administer it prior to drop-off or return to administer it at the appropriate time.I acknowledge that drop-in childcare is limited to not more than 4 hours per day except when in-person class time exceeds 4 hours. Childcare only covers times when I am required to attend in person classes or up to 90 minutes of lab/study time in a designated campus lab.I pledge that I will be on campus, in the identified class or lab space, at all times while my child(ren) are in childcare.I pledge that I will be available by phone at the number provided above during all times my child(ren) are in childcare.I understand that childcare is provided on a first come-first serve basis, and that acceptance of my child will depend on total enrollment at time of drop-offI acknowledge that any violation of these rules will immediately disqualify me from future use of this childcare service.I waive Isothermal Community College and its employees from any and all liability to extent allowed by the law.
terms and conditions calculation
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