Waitlist & Inquiry Form 
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Email *
Child Name:  *
Child date of birth: *
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How old is your child?  *
Days of Care Needed *
Required
Pick up & drop off times                                          (example, M-Tu-W 8-3, Th-Friday 9-5) *
Site Preference (more than 1 choice allowed) *
Required
Interested in School Age Before & After Care? *
IF interested in Before/After service, which school does your child attend?
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Interested in what type of care? *
Is your child potty trained (less than 2 accidents a week)?
Clear selection
I am or may be interested in the FREE 4 year old preschool program and my child turned 4 on or before December 1st, 2025. *
Do you need Full Time or Part Time services? *
Required
Does your child have any medically diagnosed conditions or behavioral needs (aggression, biting, escaping) that require specialized training or a 1:1 child to teacher ratio?  If so, please explain. *
Parent first & last name *
Parent phone number: *
OK to text message? *
Why are you interested in services? *
Has your child ever been in a child care center setting? *
How long do you plan to use services? *
Payment type: *
Would you like help sending a DHHS Provider Verification for child care subsidy? *
Desired Start Date? (Phoenix cannot hold unpaid slots for more than 1 week) *
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I would like to schedule a tour. 
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If we are not able to serve your need at the moment, would you like us to contact you when space becomes available? *
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How did you hear about Phoenix?  *
Did a Phoenix parent or staff refer you?  If so, who?
 *
Anything else you would like us to know? *
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