Request for Child Care

Date of Request*
MM slash DD slash YYYY
When care is needed*
Parents / Guardian Name*
Address*
Home Phone*
Alt Phone
Please add child 1 information below.
Child 1 - Name*
Child 1 - DOB*
MM slash DD slash YYYY
Child 1 - Age*
Child 1 - Sex*
Full time or Part time*
- Full Time
- Part Time
Hours Required*
Please add child 2 information below.
Child 2 - Name
Child 2 - DOB
MM slash DD slash YYYY
Child 2 - Age
Child 2 - Sex
Full time or Part time
- Full Time
- Part Time
Hours Required
Please add child 3 information below.
Child 3 - Name
Child 3 - DOB
MM slash DD slash YYYY
Child 3 - Age
Child 3 - Sex
Full time or Part time
- Full Time
- Part Time
Hours Required
Subsidy*
- Yes
- No
Other relevant information: Medical /emotional condition requiring treatment or supervision
Where did you hear about Children’s Choice?*