Great Bay Kids' Company

Interest Form

Please provide us with information so that we may help you.

Check if appropriate:

DCYF/Foster Care Child

Currently enrolled in a GBKC program

Currently enrolled in the GBKC agency

Sibling currently enrolled in agency

Eligible for NH Child Care Scholarship Assistance

Parent/Guardian

First Name

Last Name

Street Address

City

State

Zip

E-mail Address

Cell phone

Home phone

Work phone

Parent's Place of Employment

Child's

First name

Last name

Date of Birth

Please enter the month and year you are interest in having your child enroll:

Month

Year

Site interested in:

Age Group interested in:

Scheduling needs

Mon Tues Wed Thurs Fri

Hours (i.e. 8 am to 4 pm)

How did you hear about our agency?

Please check all that apply:

I would like information about your program sent to the address listed above.

I would like information about your program e-mailed to me at the email address listed above.

I would like a tour of the center/site

I am not interested in any information at this time. Please call me when you have a spot for my child.