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

No

Your School District*

Child's Regular School*

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

No

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

Send me a copy of my responses

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