Friendship Village | Childcare Waiting List

Date:

Are you a current Friendship Village Employee?

Yes

No

Are you a current MercyOne Employee?

Yes

No

Child's Name:

Date of Birth:

Mother’s Name:

Phone:

Mother’s Address:

Email:

Mother’s Employer:

Father’s Name:

Phone:

Father’s Address:

Email:

Father’s Employer:

Date you wish to enroll your child?

Days and hours you would like your child to attend:

Do you wish for us to contact you if space should become available after the date you wish to enroll your child?

Yes

No

Free Text

Expected payment method:

New Field:

Private Pay

Childcare Assistance (CCA)

I understand that my child is not guaranteed placement at It Takes a Village Childcare, LLC. I also understand that families are contacted according to the order of dated waiting list forms as well as space availability on the days requested above.

Yes

Free Text

*At the time of notification of space, families will have a period of five working days to respond. If we do not receive a response within this time, your child will automatically be removed from the waiting list.

Initials:

Waiting List Form

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