Form

SWI Childcare Registration

Please complete form for as many children as will be in childcare
We will accept childcare requests for Term III and/or Term IV beginning January 1, 2013. Please do not submit requests prior to January 1 as these will not be honored.

We again encourage dads to stay home with the children if at all possible. We have a limited number of spaces available in each age group. We will do our best to accommodate everyone until all the spaced ar filled. We will fill requests based on the order in which they are received after January 1. You will receive an email confirmation once your request has been processed.

The subsidized cost is $2.00 per child per occurence. The fee is paid when you drop you children off in their respective childcare rooms in the second floor of the Honeycutt hallway. You may choose to prepay for the entire term or pay each week.

Wednesday morning care is available from 9:45am-12pm only during term III.

Thursday evening care is available from 6:45-9:00pm.

Cancellations for childcare each week must be emailed to Rebekah Lee (rlee@sbts.edu) no later than Monday.
Mom's Name*
First Name Last Name
Preferred Phone Number*
- Area Code Phone Number
Preferred Email Address:*
Emergency contact*
First Name Last Name
Emergency Contact Number*
- Area Code Phone Number
I'm requesting childcare for*

Term III only Term IV only both Terms III & IV
I'm requesting childcare on*

Wednesday mornings only Thursday nights only both Wednesday mornings and Thursday nights
I'm requesting*

Standing Reservations (care expected weekly unless I cancel by Monday) Occasional Reservations (care by request only)
If you already know the dates of when you will need occasional care, please list them here. You may skip this field if you are unsure.
I need childcare because, during my class, my husband is*

working in class
Please list the SWI class(es) you will be taking this semester:*

Child 1
First Name:*
Birth Date*
Month Day Year
Age*
Sex*
Please list any health concerns or allergies.*

Child 2
First Name:
Birth Date
Month Day Year
Age
Birth Date
Month Day Year
Sex
Please list any health concerns or allergies.

Child 3
First Name:
Birth Date
Month Day Year
Age
Sex
Please list any health concerns or allergies.

Child 4
First Name:
Birth Date
Month Day Year
Age
Sex
Please list any health concerns or allergies.

Child 5
First Name:
Birth Date
Month Day Year
Age
Sex
Please list any health concerns or allergies.

Child 6
First Name:
Birth Date
Month Day Year
Age
Sex
Please list any health concerns or allergies.

Submit
By clicking submit, you are confirming that all of the above information is correct.
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