Child Care Application
Date of Application_______________________________ Date Received________________
Child's Name______________________________________ Date of Birth________________
Address_____________________________________________________________________
Home Telephone Number_______________________________________________________
Father's Name________________________________________ County Employee__Yes__No
Place of Employment__________________________________________________________
Address_____________________________________________________________________
Position Held________________________ Telephone # (______)______________________
Mother's Name________________________________________ County Employee__Yes__No
Place of Employment__________________________________________________________
Address_____________________________________________________________________
Position Held________________________ Telephone # (______)______________________
Marital Status:_________Married_________Separated_________Divorced________Single
Emergency Contact_______________________ Relationship to Child__________________
Telephone Number: Home (______)________________ Business (______)_______________
Child Care Needs:__________Immediate or Future Start Date______________________
Special Needs/Concerns________________________________________________________
___________________________________________________________________________
Parent’s Signature: ___________________________________________________________
Date of Application_______________________________ Date Received________________
Child's Name______________________________________ Date of Birth________________
Address_____________________________________________________________________
Home Telephone Number_______________________________________________________
Father's Name________________________________________ County Employee__Yes__No
Place of Employment__________________________________________________________
Address_____________________________________________________________________
Position Held________________________ Telephone # (______)______________________
Mother's Name________________________________________ County Employee__Yes__No
Place of Employment__________________________________________________________
Address_____________________________________________________________________
Position Held________________________ Telephone # (______)______________________
Marital Status:_________Married_________Separated_________Divorced________Single
Emergency Contact_______________________ Relationship to Child__________________
Telephone Number: Home (______)________________ Business (______)_______________
Child Care Needs:__________Immediate or Future Start Date______________________
Special Needs/Concerns________________________________________________________
___________________________________________________________________________
Parent’s Signature: ___________________________________________________________