1745 Copperhill Parkway Suite #5
Santa Rosa, CA 95403
707.545.2402
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EXTENDED CHILD CARE OF SONOMA COUNTY
1745 COPPERHILL PKWY, SUITE 5 SANTA ROSA CA 95403
TEL (707) 545-2402 FAX (707) 222-6233
Full Cost Wait-List Application for New Families
This is an application to be placed on our wait-list only. It does not guarantee enrollment in our child care program.
PARENT INFORMATION
*
Indicates required field
Parent Name
*
First
Last
Relationship to Child
*
Home Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
How did you hear about us?
*
Internet Search
School
Friend
Other
CHILD INFORMATION
**
Please complete one wait-list application per child
**
Child's name:
*
First
Last
Child care needed for school year:
*
School Attending:
*
Gender:
*
Male
Female
Birth Date
*
Grade Level
*
Are there any special needs we need to be aware of?
*
Yes
No
If yes, please describe special needs:
*
Does you child have any severe allergies or medical conditions?
*
Yes
No
If yes, please explain:
*
Will medication be administered at the center?
*
Yes
No
CHILD CARE SCHEDULE NEEDED
**
3 day minimum required
**
Schedule per week needed
Will you need care on non-school days? (winter break, spring break, teacher in-service days)
*
Yes
No
ECC offers two enrollment options during the school year. Option 1: Schedules which include all Non-School Days, such as Winter Break, Spring Break, teacher in service days, etc. Option 2: Schedule with SCHOOL DAYS ONLY.
Check One
*
5 Days
4 Days
3 Days
Check all that apply
*
Monday
Tuesday
Wednesday
Thursday
Friday
Check One
*
Before School Only
After School Only
Before School AND After School
Applicant Signature:
*
Please type your name.
Date:
*
Submit
