In-Home After-School Support Request
Share your contact details, your child’s information, and your after-school schedule preferences.
Parent / Guardian First Name
*
Parent / Guardian Last Name
*
Primary Email
*
example@example.com
Secondary Email
example@example.com
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child Name
*
Grade
*
School
Does your child have an IEP, 504, or identified support needs?
*
Please Select
Yes
No
Not sure
Days Needed
*
Monday
Tuesday
Wednesday
Thursday
Friday
Daily After-School Care Duration
*
2 hours/day
2.5 hours/day
3 hours/day
Anything you'd like us to know about your child or schedule?
Address where support will take place.
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand that in-home after-school support requires a minimum weekly commitment, is scheduled based on provider availability, and reserved time may be counted as used if cancelled without sufficient notice. This is a request and does not confirm services.
*
I agree
Submit
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