Centrepointe Childcare Services

TO BETTER SERVE YOU AND YOUR CHILD'S NEEDS, PLEASE FILL IN THE FOLLOWING INFORMATION: A Director will contact you when a space becomes available which meets your family's needs.

Group Care

Home Care

Nursery School

Age group: 18 months - 5 yrs.

	Full Fee	Subsidy
Group Care:

Full time enrollment required

Age group: 3 months - 10 yrs.

	Full Fee	Subsidy
Home Care:

Full time Part time

Age group: 3 & 4 yrs.


Nursery School:

Two morning sessions/wk

Date you require care:

Does your child have any special needs we should be aware? (Medical, emotional, intellectual, or physical): If yes:

Parent's Name:

Address:

City: Postal Code:

Telephone:	Home:	E-mail:
	Work:	ext:

Child Information:
Child's Name	Date of Birth (MM/DD/YY)	Current Childcare Arrangement

Specific Questions for Home Care Applicants:

Home Care Area Preferred:

Days of care required:

Hours of care required: From am to pm

Do you prefer your child to be with other children? yes no

If yes, what ages:

Is it important to you that the provider have a structured day?
Very Less Not at all

School child is attending:

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