After School Care Inquiry Form
Please complete this form to inquire about after school care. All fields are optional unless otherwise indicated.
Date of Inquiry
-
Month
-
Day
Year
Date
Parent/Guardian Name
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Valid Email Address
*
example@example.com
Address
1st Child's Full Name
*
Child Date of Birth
*
-
Month
-
Day
Year
Date
Child Age
*
Child Grade
*
School Attending
*
Requested Start Date
*
-
Month
-
Day
Year
Date
2nd Child's Full Name
Child Date of Birth
-
Month
-
Day
Year
Date
Child Age
Child Grade
School Attending
Requested Start Date
-
Month
-
Day
Year
Date
3rd Child's Full Name
Child Date of Birth
-
Month
-
Day
Year
Date
Child Age
Child Grade
School Attending
Requested Start Date
-
Month
-
Day
Year
Date
Full Time Enrollment (5 days) $100.00 Per Week, Per Child:
*
Yes
No
Part-Time Enrollment (3 days) Select Days Needed: $85.00 Per Week, Per Child
Monday
Tuesday
Wednesday
Thursday
Friday
DSS Tuition Scholarship?
*
Yes
No
Allergies/Medical Needs
*
No
Yes
Allergies/Medical Needs - Explanation
Special Accommodations/Behavioral Support Needs
*
No
Yes
Special Accommodations/Behavioral Support Needs - Explanation
Emergency or important information to know
Parent Questions/Notes
Do you have a ChildPilot Childcare Management System profile?
*
Yes
No
How did you hear about us?
Parent/Guardian Signature
*
Parent/Guardian Signature Date
*
-
Month
-
Day
Year
Date
OFFICE USE ONLY - Status
Space Available
Waitlist
Enrollment Packet Given
DSS Forms Needed
OFFICE USE ONLY - Staff Initials
Submit
Submit
Should be Empty: