PlayWorks Application - Springfield Area Parent Child Center

Today's Date

Child's Name

First Last

Child's Date of Birth

Please indicate the days requested for child care services

Please indicate hours preferred.

We offer block scheduling, which means you can choose either a 7:30 or 8:30 drop off time and a 3:00, 4:30 or 5:30 pick up time.

Requested Starting Date

Parent/Guardian Name

First Last

Additional Parent/Guardian Name (optional)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone

Cell

Does this child have a sibling that is already enrolled at PlayWorks?

Yes
No

Is parent a student or in a training program?

Yes
No

If "Yes", what school/program is parent in?

Parent/Guardian Signature

Your submission of this form serves as your signature that you agree to being placed on the wait list for PlayWorks Child Center and to being contacted when there is an opening. This application needs to be filled out every 6 months in order to hold your spot on the wait list. Thank you!