Date: ____________________

1st Child Information
First Name: ____________________     Last Name: ____________________
Birth Date: ____________________      Child’s Gender:  Male [   ]  Female [    ]
Address: ___________________________________
City: _______ State: _______ Zip: _______ Telephone: __________________
Has your child attended a childcare? If so, Reason for leaving:
___________________________________________

Anticipated Start Date: ________________________
Check which days of the week is needed:
Monday [   ]  Tuesday [    ]  Wednesday [    ]  Thursday [    ]  Friday  [    ]
Indicate whether you need   Full time [    ] or Part-time [    ] Hours:  _____a.m.  _____p.m.


2nd Child Information
First Name: ____________________     Last Name: ____________________
Birth Date: ____________________      Child’s Gender:  Male [   ]  Female [    ]
Address: ___________________________________
City: _______ State: _______ Zip: _______ Telephone: __________________

Has your child attended a childcare? If so, Reason for leaving:
___________________________________________

Anticipated Start Date: ________________________
Check which days of the week is needed:
Monday [   ]  Tuesday [    ]  Wednesday [    ]  Thursday [    ]  Friday  [    ]
Indicate whether you need   Full time [    ] or Part-time [    ] Hours:  _____a.m.  _____p.m.
Parent/Guardian Information

Mother’s Name: _________________   Father’s Name: _________________
Phone #: _______________________    Phone #: ______________________
Email: _________________________     Email: ________________________


Email this form to steppingstones.easton@gmail.com

We will notify the next child on the list when the space becomes available.

We will also move the Applications to the age-appropriate group as the child increases in age.
You can call or email us to check on the status of the waiting list.

 Please reach out to us if alternative care has been found and want your name removed from the waiting list.


Parent’s Signature: _______________