Community and In-Home Inquiry Form

Pacekids Programs Community and In-Home Inquiry Form

Child's Full Name

Child's Date of Birth

Child's School Name

Child's School Hours

Parent/Guardian Name

Phone

Address (Including city to confirm programming availability)

Timeslot(s) you and your child are available for programming (Pacekids offers programming Monday - Friday. For scheduling purposes, families must be available for programming 3- 4 days a week at the same time each day)

10:00am -12:00pm 1:00pm -3:00pm 4:00pm -6:00pm

Do you have an active FSCD agreement and caseworker

Languages most frequently spoken at home:

Would you like registration support in your preferred language?

Yes No

How did you hear about Pacekids?

If you selected a referral option or "Other," please share any additional details such as a name, clinic, or organization:

Subscribe me to the Pacekids e-newsletter for the latest updates and resources.

Yes No

Please read and confirm to complete your form

By checking this box, I confirm the information above is accurate.

Thank you for your interest in Pacekids Community and In-Home Programs.

Our C&IH Coordinators will respond as soon as possible. If this is urgent, please call 403-234-7876.

Pacekids Programs Community and In-Home Inquiry Form

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