Childcare Inquiry/Application

Family

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Gender

Female

Male

Other

Parent/Guardian Name(Required)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Work/School Phone

Mother/Guardian Place of Employment/School

Father/Guardian Place of Employment/School

Childcare Needs

When would you like your child to start in the program?(Required)

Hours needed(Required)

My child also participates in the following programs:

How did you hear about our program?(Required)

Have you participated in any other Family Resource Center or Child & Family Agency programs?(Required)

Yes

Please list the programs you have participated in(Required)

Financial

You may apply for a sliding scale fee which is based on family income and size. Please supply the following information.

Total Household Income before taxes (including child support, alimony, State assistance, etc.) Weekly:

Number of individuals living at this address:

A non-refundable application fee is charged for each child.

Child

Please indicate any limitations, restrictions or concerns you may have for your child (i.e.: dietary, fears, allergies, toileting, etc.).(Required)

So that we may plan for any necessary and helpful supports, please note any medical, behavioral, or emotional concerns you or others have noted regarding your child.(Required)

Has your child received any specialized evaluations (e.g. medical, neurological, developmental, psychological/psychiatric)? This information is helpful in planning for the most appropriate child care.(Required)

Yes

If yes to the above, Please list the type(s) of evaluation and where and when they were received.(Required)

Type of Evaluation

Where

Date

Please list any other child care your child has received outside of your home and include the dates attended.

Childcare Setting

Month/Year Enrolled

Month/Year Left

Acknowledgement of Information Provided(Required)

By signing below, I acknowledge the information I have provided is accurate. Failure to provide accurate information may disqualify a child from acceptance and participation.

Parent/Guardian Signature(Required)

Today's Date(Required)