St. Louis Youth Services
Please complete the form below for childcare in St. Louis, Mo
Parent/ Guardian Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
month/day/year
Phone Number
*
-
Area Code
Phone Number
Emergency/ Contact Name
*
First Name
Middle Initial
Last Name
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
month/day/year
What High School did you go to?
*
Child Name
*
First Name
Middle Initial
Last Name
Age
*
Child Name
First Name
Middle Initial
Last Name
Age
Child Name
First Name
Middle Initial
Last Name
Age
Child Name
First Name
Middle Initial
Last Name
Age
Child Name
First Name
Middle Initial
Last Name
Age
Child Name
First Name
Middle Initial
Last Name
Age
Email Address
*
How many hours will you need and on what days will you need them a week between the hours of 9am07pm Monday - Friday & 10am-6pm on Saturdays?
*
What area does your child/children live?
*
North St. Louis City
West St. Louis City
South St. Louis City
Downtown St. Louis City
St. Louis County
North St. Louis County
South St. Louis County
East St. Louis
Other
What does your child/children like?
*
Sports
Video Games
Singing
Dance
Art
Food
Books
Outdoors
What type of phone or device does you or your child own?
*
Android Phone or Tablet
Apple/iPhone/iPad
Other
Is your child allergic to anything?
*
The Legal Guardian will provide all medications needed in case or medical emergencies, Reply "yes" or "a variation of yes" to confirm that you the signee assumes this responsibility
*
Does your child know their address and/or parent or guardian number?
*
Are your children potty trained?
*
Can you supply your own diapers?
*
Are any of your children interested in studying any of these career fields?
*
Trade School
Music or TV Career
Medical
Farming
Military
Art
Engineering
Barber/Beauty
Business or Entrepreneurship
Economics
Automotive + Aerospace
Law
Tech/ Content Creation
Any questions that you have about the program?
*
Any thing we should know about your child/children?
Submit
Should be Empty: