Please call our facility or complete this form so I can better serve your needs     

Name:
Email Address:
Phone Number
Cell Phone or Work Number
Start date needed.
Age of first child:	6 Weeks 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 12 Months 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year Other
Age of second child	6 Weeks 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 12 Months 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year Other
Age of third child:	6 Weeks 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 12 Months 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year Other
If pregnant when is your due date?
What hours do you need care?
Do you need:	Full Time Care 5 Days 7:00-5:00 Full Time Care 5 Days Part Time Care 4 Days Part Time Care 3 Days Drop In Care Parent Night Out 5 Year-Pre-School 9:00am-3:00pm 4 Year-Pre-School 9:00am-3:00pm 3 Year-Head Start 9:00am-3:00pm 2 Year-Head Start 9:00am-3:00pm Head Start B&A Care Before Care After Care Other
Do you need school age care, if yes please select the care needed below:	Before School After School Before & After school Care Not at this time
High Point Elementary School is my child's school zone.	Yes No Not Sure
Please inform me of any other useful information that could be helpful to better serve you.
When is the best time to schedule your interview? Date, time etc.
How did you hear of ACW Childcare & Pre-School?	Internet Search Road Sign Friend Store In Store Sign Local Ad Craigs List Kijiji Child Care Connections CCA Md. Penny Saver Flyer in mail Flyer in store Other
If you selected other please describe?

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