Emergency PopUp Childcare Registration Form
Thank you for your interest in the Emergency PopUp Childcare, which is open to all essential workers.

Please note that as of May 8, 2020 all TK-5 programs, as well as infant / toddler and preschool programs are at or near capacity. You are welcome to apply, and will be contacted should space be available or open up. Space is still available in the program for 6th - 12th grade at the South Novato Library.

For program overview, please visit: https://docs.google.com/document/d/1W6JthFm56yLKpC9yJO__YkUDXHauy1yzs8bAzHXnt24/preview
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First Name
Last Name
Where you work
Clear selection
Your position
Your cell phone number (###-###-####)
Your preferred email address *
Child #1: Age/Grade Level
Child #1 Date of Birth
MM
/
DD
/
YYYY
Child #2: Age/Grade Level
Child #2 Date of Birth
MM
/
DD
/
YYYY
Child #3: Age/Grade Level
Child #3 Date of Birth
MM
/
DD
/
YYYY
Child #4: Age/Grade Level
Child #4 Date of Birth
MM
/
DD
/
YYYY
Child #5: Age/Grade Level
Child #5 Date of Birth
MM
/
DD
/
YYYY
Preferred location for children in grades K-5 (THIS IS NOT GUARANTEED)
If you have a child with special needs, please describe them BRIEFLY. After your services are confirmed, you will have an opportunity to share more information with your caregiver.
First day requiring childcare
MM
/
DD
/
YYYY
Drop off time on first day
Time
:
How many days and hours a week do you need consistent child care?
What days of the week and approximate hours do you anticipate you will need childcare?
Monday
Tuesday
Wednesday
Thursday
Friday
7 am - 8 am
8 am - 12 pm
12 pm - 5 pm
5 pm - 7 pm
Check all that apply:
Explain why child care is needed. Include any relevant information that will help us assess your need. You can elaborate based on your answers from above. *
Any additional comments and questions.
Submit
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