Schedule Request Form


Schedule Request Form Please submit one form per child. Fields marked with a red asterisk ()are Required*.
Child's Name:	*
Child's Birth Date:	*
Gender:	*	Male Female
Desired Starting Date:	*
Desired Program	*	Peanut Patch (12 - 18 months) Toddler Town (19 - 30 months) Transitional Preschool ( 2 1/2 - 3 1/2 years) Pre-School ( 3 1/2 - 4 years) Pre-Kindergarten (4 - 5 years) Kindergarten For School Age Program use seperate schedule request form
Tuition Payment Method:	*	Personal Funds DSHS

Desired Schedule Please check all time slots requested. Add special notes to the "Special Need/Requests" field below. Thanks.
Monday:		AM PM
Tuesday:		AM PM
Wednesday:		AM PM
Thursday:		AM PM
Friday:		AM PM
Special Needs/Requests: (i.e. dietary requirements, scheduling needs, etc.)

Contact Information
Child Lives With:	*
Parent's First Name:	*
Parent's Last Name:	*
Address:	*
City:	*
State	*
ZIP Code:	*
Home Phone:	*
Email Address:	*
Employer:
Work Phone:
Today's Date:	*
A Schedule Request is the first step in determining whether or not we have an opening for your child to attend Hillcrest Kids. We will contact you either by email or phone to let you know about availability. If and when you accept an opening in our program, you are responsible to pay the annual registration fee by a date set up by yourself and the scheduling manager. In addition, once the registration fee has been paid, you are responsible to give a two week notice in the event you decide to withdraw from our program. For families receiving state assistance, the annual registration fee is also required when an opening is accepted. Once the state authorizes payment towards the fee, a credit will be applied to your account, which will go towards the amount of your monthly copay. To accept the terms of this agreement and send your schedule request, please click on "Submit."