Contact

200 Farrington Street
Terre Haute, IN, 47807
Phone: 812-237-2547
Fax: 812-237-8705

Open:
Monday - Friday
7:15 AM - 5:15 PM

Directions

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Child Care Application

Child's Information

First Name: Add child's first name Last Name: Add child's last name

Date of Birth:

Gender:

Child lives with:

If "other", please specify:

Parent/Guardian Information

Full Name: Add your name

Relation:

Address: Add your address

City: Add city of residence State:

Zip: Add your zip code

ISU Affiliation: Student Faculty Staff Non-ISU

991#: Leave blank if Non-ISU

Hours enrolled: Occupation: Employer: Home/Cell Phone:

Work Phone:

Email: Add your email address

Parent/Guardian 2 Information

Full Name: Add your name

Relation:

Lives at the same address as Parent/Guardian 1

Address: Add your address

City: Add city of residence State:

Zip: Add your zip code

ISU Affiliation: Student Faculty Staff Non-ISU

991#: Leave blank if Non-ISU

Hours enrolled: Occupation: Employer: Work Phone: Cell Phone:

Email: Add your email address

Preferred Start Date/Other Information

Requested start date:

Child's age: At time of start date

List any special needs:

Do you have more than one child who needs care, or do you currently have a child enrolled in our program? If so, please list their names and ages. (A separate application must be filled out for each child applying to our program).

How did you hear about our program?

Please select one:

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