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
**CURRENTLY ENROLLED SUBSIDIZED FAMILIES ONLY**
This application is ONLY for families that have a child enrolled in an ECC center.
Due to COVID-19, districts are moving toward a 100% distance learning model when school opens in August. All ECC centers will be open from 8:00 AM - 6:00 PM, Monday - Friday. Currently, the Sonoma County Health Ordinance limits child care to no more than 12 children per classroom.
SPACE IS EXTREMELY LIMITED
. Completing this form does not guarantee enrollment in our child care program.
We will be providing breakfast, lunch and snacks daily.
ECC is working with each district to ensure our staff have the necessary resources to support your child's Distance Learning while they are in care.
PARENT INFORMATION
*
Indicates required field
Parent Name
*
First
Last
Relationship to Child
*
Is your work considered "ESSENTIAL".
*
YES
NO
Does your employer allow for you to work from home or telecommute?
*
YES
NO
Phone Number
*
Email
*
CHILD INFORMATION
**
Please complete one application per child
**
Child's name:
*
First
Last
School Attending:
*
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
**
DUE TO CURRENT RESTRICTIONS and LIMITED SPACE, 5 DAY PER WEEK SCHEDULES WILL BE THE HIGHEST PRIORITY.
Schedule per week needed
Check One
*
5 Days
4 Days
3 Days
Check all that apply
*
Monday
Tuesday
Wednesday
Thursday
Friday
Check One
*
Half Day Schedule (up to 6 hours)
Full Day Schedule (6.5 - 10 hours)
Applicant Signature:
*
Please type your name.
Date:
*
Submit