Hemel House Care Search
Basic Information
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Date:
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Parent Name (first and last):
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Home Address:
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Postal Code:
Home Phone:
Cell Phone:
E-mail:
Place of Work or School:
Work or School Phone:
Care Start Date:
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What areas of the city are you willing to look?
South
North
West
Is transportation required for school?
Yes
No
Child Information
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Child Name:
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Birthdate(yyyy-mm-dd):
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Male
Female
Child Name:
Birthdate(yyyy-mm-dd):
Male
Female
Child Name:
Birthdate(yyyy-mm-dd):
Male
Female
Care Details
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Days needing care:
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Hours Needing Care - (Please include potential drop off and pick up times):
Special needs, allergies, medical needs?
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Can the day home have pets?
Yes
No
Only specific ones
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Will you be applying for subsidy?
Yes
No
Other Information:
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Indicates Response Required
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