Childcare Inquiry/Application Childcare Inquiry/ApplicationFamilyChild's Name(Required) First Last Child's Date of Birth(Required) MM slash DD slash YYYY Gender Female Male Other Parent/Guardian Name(Required) First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone(Required)Work/School PhoneEmail Mother/Guardian Place of Employment/School Father/Guardian Place of Employment/School Childcare NeedsWhen would you like your child to start in the program?(Required) MM slash DD slash YYYY Hours needed(Required) My child also participates in the following programs: Add RemoveHow did you hear about our program?(Required) Have you participated in any other Family Resource Center or Child & Family Agency programs?(Required) Yes No Please list the programs you have participated in(Required) FinancialYou 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.ChildPlease 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 No If yes to the above, Please list the type(s) of evaluation and where and when they were received.(Required)Type of EvaluationWhereDate Add RemovePlease list any other child care your child has received outside of your home and include the dates attended.Childcare SettingMonth/Year EnrolledMonth/Year Left Add RemoveAcknowledgement 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) MM slash DD slash YYYY
