Child Care Inquiry Form

IF WE HAVE A WAITLIST WE WILL PLACE YOU ON IT AND CONTACT YOU AS SOON AS A SPOT OPENS FOR YOUR CHILD.
Parent/Guardian Name to contact*

First NameLast Name
Email*
example@example.com
Best Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Child's Details
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemalePrefer not to answer
Full-Time (25+ hours per week)Part-Time (24.9 hours or less a week)

Attendance: Please pick the days you would like your child to attend and write approximate times*

Desired start date*

MonthDayYear
Date
Primary Language spoken by child and family*
If other than English, what is the child's English proficiency?*
Does your child have a a disability or do you have any concerns about your child's development? If yes, please explain.*
Does your child require any social/emotional support? If yes, please explain.*
YesNo
Should be Empty: