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Child and Family Agency

Child and Family Agency

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Childcare Inquiry/Application


Childcare Inquiry/Application

Childcare Inquiry/Application

Family

Child's Name(Required)
MM slash DD slash YYYY
Gender

Parent/Guardian Name(Required)
Address

Childcare Needs

MM slash DD slash YYYY
My child also participates in the following programs:
Have you participated in any other Family Resource Center or Child & Family Agency programs?(Required)

Financial

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

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

Child

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)
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)
MM slash DD slash YYYY
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