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

Our cutoff time for daily placement is 4 pm. You'll be contacted via email or call within 24 hours. To be guaranteed a spot, you must confirm acceptance within 24 hours.

Vallecito Elementary (K-5) - approaching capacity. Please mark your secondary choice.

For program overview, please visit: https://docs.google.com/document/d/1W6JthFm56yLKpC9yJO__YkUDXHauy1yzs8bAzHXnt24/preview
First Name
Your answer
Last Name
Your answer
Where you work
Your position
Your answer
Your cell phone number (###-###-####)
Your answer
Your preferred email address *
Your answer
Child #1: Age/Grade Level
Child #1 Date of Birth
Date
Child #2: Age/Grade Level
Child #2 Date of Birth
Date
Child #3: Age/Grade Level
Child #3 Date of Birth
Date
Child #4: Age/Grade Level
Child #4 Date of Birth
Date
Child #5: Age/Grade Level
Child #5 Date of Birth
Date
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.
Your answer
First day requiring childcare
Date
Drop off time on first day
Time
:
How many days and hours a week do you need consistent child care?
Your answer
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. *
Your answer
Any additional comments and questions.
Your answer
Submit
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