Pathway Inclusion Center Child Care Wait List
Filling out this form does not bind you to receiving services, nor does it reserve a specific date or time for child care. This information will only be used as a waiting list. We will contact you in the order your information is received once we begin child care enrollment. Thank you!

NOTE: At this time, Pathway Inclusion Center is accepting 18 months-12 years for our waiting list (ages 6-12 years is partial day only). This does NOT guarantee that these ages will all be accommodated nor does this guarantee your child a spot. Services are first come, first serve based on the amount of space in each classroom. We hope to expand our services as quickly as funding allows. Donations can be made at www.pathwayinclusion.org/donate.

Contact Information
We will use this information to contact you once we begin enrollment. If your contact info changes, please contact us at info@pathwayinclusion.org.
Parent/Guardian or Adult Last Name *
Your answer
Parent/Guardian or Adult First Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone *
Your answer
Email *
Your answer
Person(s) Receiving Child Care
Please only fill out for child(ren) or individual you wish to receive child care.
1st Individual/Child Name, Birthdate *
Your answer
2nd Individual/Child Name, Birthdate
Your answer
3rd Individual/Child Name, Birthdate
Your answer
4th Individual/Child Name, Birthdate
Your answer
5th Individual/Child Name, Birthdate
Your answer
6th Individual/Child Name, Birthdate
Your answer
Is your child(ren) currently enrolled in a child care program? *
If yes, where?
Your answer
Does your child(ren) have special needs? If yes, which child and what type of needs? Add diagnosis(es) if available. *
Your answer
Other comments or questions.
Your answer
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