Champions @ Hermiston SD Full Day Care Request

Please fill out one form per child, we will be in touch with you to confirm enrollment. Thank you!

Parent Name

Employer

Job Title

Email Address

Phone Number

Child's Name

Currently Enrolled in Champions?

Yes

Your School District

Child's Regular School

Consent to release and exchange information

Please check the box to allow exchange of information with the school district

Consent to release and exchange information

Using State Subsidy for Tuition (Link Available)

https://www.oregon.gov/DHS/ASSISTANCE/CHILD-CARE/Pages/ERDC-COVID19-Emergency.aspx

Yes

Dates for Care

Please check all dates below you would like to request care for.

Monday 5/11

Tuesday 5/12

Wednesday 5/13

Thursday 5/14

Friday 5/15

Monday 5/18

Tuesday 5/19

Wednesday 5/20

Thursday 5/21

Friday 5/22

Tuesday 5/26

Wednesday 5/27

Thursday 5/28

Friday 5/29

Monday 6/1

Tuesday 6/2

Wednesday 6/3

Thursday 6/4

Friday 6/5

Monday 6/8

Tuesday 6/9

Wednesday 6/10

Thursday 6/11

Friday 6/12

Monday 6/15

Tuesday 6/16

Wednesday 6/17

Thursday 6/18

Friday 6/19

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