Child Care Inquiry

Child Care - Parent Inquiry

NOTE:: We are sensitive to your privacy.
The information in this form will be sent to us by unencrypted e-mail through the internet.
If you are uncomfortable with this, please download the PDF version of this form and open it with Adobe Acrobat Reader. There you may fill it out, print it then either fax, mail or bring it into our office. Please contact us if you have any questions.

Child Care - Parent Inquiry

Parent Inquiry Form

Items marked with a red asterix (*) are required.

Submitter Information:

Your Full Name*:

Parent / Guardian Information:

	Parent's Name:
Given Name *
Surname *
Address:
Street
City
Province
Postal Code
Contact Info:
Phone (Home)* Format: xxx-xxx-xxxx
Phone (Cell)
Parent's E-mail*:

Children requiring care:

(Please fill out a separate application for each child.)
Given Name	Surname	Birth Date (dd/mm/yy)

Required Care Schedule:

Desired Start Date (dd/mm/yy)
Days:		Hours:
	Mon
	Tue
	Wed
	Thu
	Fri

Medical Information:

Explain any allergies (Food, Drugs, Environment, etc.) or concerns

Other:

Please indicate any other information, preferences, expectations or concerns you may have
that will be of use to the Provider or agency.