Full Cost Wait-List Application

This is an application to be placed on our wait-list only. It does not guarantee enrollment in our child care program.

PARENT INFORMATION

How did you hear about us? *

Internet Search School Friend Other

CHILD INFORMATION **Please complete one wait-list application per child**

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: *

CHILD CARE SCHEDULE NEEDED **3 day minimum required**

Will you need care on non-school days? (winter break, spring break, teacher in-service days) *

Yes No

EXTENDED CHILD CARE OF SONOMA COUNTY

1745 COPPERHILL PKWY, SUITE 5 SANTA ROSA CA 95403
TEL (707) 545-2402 FAX (707) 222-6233