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Waiting Pool Application

Thank you for inquiring about our Child Care Center. Please complete the following information in order to assist us in attempting to meet your childcare needs. Completion of this application is not a guarantee of availability of a slot for your child(ren). We are unable to foresee availability.

Parent(s) Information:

Please Check: Scripps Health   TSRI   Community
Title:
Last Name:
First Name:
Work Place:
Department:
 Scripps Health Employee ID # (if applicable):
Work Phone:
Mail Drop:
E-mail Address:
Title:
Last Name:
First Name:
Work Place:
Department:
 Scripps Health Employee ID # (if applicable):
Work Phone:
Mail Drop:
E-mail Address:

Home Address

Street Address:
City:
State:
Zip Code:
Home Phone:
Child's (Children's) Name(s):Date of Birth/Due Date:

Preferred Starting Date: Note: This is not a guarantee that childcare will be available at this time. Please make alternate arrangements until we contact you with an opening.

Days of Week Care is Needed: Monday through Friday   Monday, Wednesday, Friday   Tuesday, Thursday

If full-time care is desired, would you consider a part-time slot if it became available before full-time? Yes No