Child Care Screening Form

If you are interested in applying for Child Care please fill out the Child Care Screening Form and a Family Worker will contact you as soon as possible!!

Child Care Screening

Child's Name *

Birthdate *

Parent's Name or Legal Guardian *

Relationship to Child: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Please enter the best contact number

Can this phone receive text messages? *

YES
NO

Email *

Email

Confirm Email

Please enter an email that you check often. We will contact you via phone and email

Second Parent's Name or Legal Guardian

Relationship to Child:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Please enter the best contact number

Email

Please enter the best email address.

Childcare program *

Abbott (3-5yrs)
Early Head Start (3months- 3yrs)
Private Class (3months- 5yrs)

***Child must be 3 yrs old by Oct. 1 of the current school year for the Abbott Program***

Estimated Income *

**Please list if the amount above is WEEKLY, MONTHLY, YEARLY

Family Size *