• CHILD CARE REQUEST FORM

    Please fill out the Child Care Request Form. All fields are required.


     

    Parent Information

     

    First Name:


     

    Last Name:


     

    Address:


     

    City:

     

    State:

     

    Zip Code:

     

    Home Phone:


     

    Cell Phone:


     

    E-mail:


     

    Home Language:



    Other Languages:   

    Gender:


     

    Financial Aid Eligible:


     

    ASAP Eligible:


     

    Ethnicity:


     

    Marital Status:


     

    Other status (please specify):


     

    Child Information

     

    Child’s Full Name:


     

    Child’s Date of Birth:


     

    Age:


     

    Gender:


     

    Type of Student:

     

    Select an option and add additional info in the fields below only when required:


     

    Major / Degree: (must add if required)

     

    Empl ID: (must add if required)

     

    CUNY College Name: (must add if required)

     

    When will you need childcare:


     

    Which of our program are you requesting for your child? (Please check all that apply):