Edgemoor Community Center
500 Duncan Road, Suite A
Wilmington, DE 19803
(302) 762-1391      www.ECC-DE.org        ecc@dca.net

Request for Child Care Services

 Name of Parent / Guardian     Date 

Daytime Tel.             Evening Tel.  

Type of Service:           Early Child Care  (6 months – Kindergarten)                                                                      School-Age Child Care - SACC (1^st through 6^th grades)

  Child’s Name:             Date of Birth:

 School District:   Brandywine                   other:

 School:           doesn’t attend                  Mt. Pleasant Elementary 

 Harlan                               Current Grade:

For Early Child Care program, check development skills.

             Independently walks                     Toilet trained

 Requested starting date for child care services:      

 
(Office Use Only)

Date Received:     Date Parent Contacted:  

Placement:                                                                                                                                        

 Information: