Child Care Opportunities

Name *

Preferred Name

Address *

Mailing Address (if different from physical address)

Phone Number *

Email Address *

Have you event been convicted of a felony? *

Yes

No

Please Explain

Are you currently enrolled in school? *

Yes

No

Where?

Are you 18 years of age or older? *

Yes

No

Please indicate the days and times that you will be available

Monday

Mornings

Afternoons

Evenings

Tuesday

Mornings

Afternoons

Evenings

Wednesday

Mornings

Afternoons

Evenings

Thursday

Mornings

Afternoons

Evenings

Friday

Mornings

Afternoons

Evenings

Saturday

Mornings

Afternoons

Evenings

Sunday

Mornings

Afternoons

Evenings

What are you interested in helping with? *

Child Care for Parenting Classes

One-Time Events

Other

Please check the boxes to indicate which area(s) you are interested in providing child care *

Polk County

Yamhill County

Please check the boxes to indicate if there are specific communities that you are interested in providing child care in

Emergency Contact *

Phone Number *

Child Care Opportunity Interest Form