Child Care Center Inquiry – Daycare Center

Use this form to inquire about the Daycare Center. Please fill out a separate form for each child.

Parent's Name*
First Last
Child's Name*
First Last
Child's Date of Birth or Due Date*
MM slash DD slash YYYY
Grade in School, if any*
Are you (select one)*
- Southwest Tech Student
- Staff or Faculty at Southwest Tech
- Community Member
Do you currently have another child attending the Child Care Center?*
- Yes
- No
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What are your child care needs?*
(ex. 40 hrs/week; M, W, F mornings from 7:30-12:30; after school care; etc.)
Is there any additional information we should know about the child?
Phone
This field is for validation purposes and should be left unchanged.