Application for Affordable Childcare

Parent's Name*

Child's Name*

Child's Birthdate*

Month

Day

Year

Address*

Phone Number*

Contact Email*

Gross Annual/Monthly Income (Please indicate if it is monthly or annual)*

Number of People in Household (including adults and children)*

Desired Start Date*

Preferred Time*

9:00 AM - 12:00 PM

9:00 AM - 3:00 PM

7:30 AM - 6:00 PM

Is the Redmond location easily accessible for you?

Yes

No

What is/are other accessible locations for you?*

Woodinville

Duvall

Kirkland

Bellevue

Sammamish

None

How did your about us?*

Google

Facebook

Word of Mouth

Referral

Other

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EMAIL*

Yes, subscribe me to your newsletter.

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Redmond, WA 98053

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