Parent's Name:

Phone Number:

Email:

Address:

Employer:

Child's Name:

Date of Birth:

Gender:

Please specify time care is needed each day:

Please check here if you are interested in applying for Financial Aid:   

If you checked yes for financial, please provide total household members & gross household income:   

Will you be approved for Social Services funding? 

Case Worker:   

Date care needed: 

Are you an employee of PHFS?

There is no application fee. However, there is a deposit of $25 due upon acceptance into the program. This deposit is not refundable.