Complete the Request for Care Form completely below to request care options for each child you would like to enroll with QCARE. When completing the form, please provide as much accurate information as you are able. Once the form is received, a member of the registration team will send an email to inform you that you have been placed on a waiting list, OR you will receive a phone call to discuss program availability and the registration process.

Your Full Name*:

Your Telephone Number(s)*:

Your Email Address(s)*:

Your Mailing Address*:

City/State/Zip Code*:

Date you wanted to start care*:
2021-22 School Year2022-23 School Year

Childs First and Last Name*:

Childs Date of Birth*:

Childs Current Grade*:
---Kindergarten1st2nd3rd4th5th6th7th

Child Districted School*:
---Atherton HoughBeechwood KnollBernazzaniLincoln HancockMerrymountMontclairParkerSouth-West MiddleSquantumWollastonOther

Do you qualify for State Voucher Subsidy?

Does your child need any special accomodations?

PROGRAM REGISTRATION CHOICES: (Please check the corresponding box next to the program and days you would like care): (Only need after school choices here for every day Mon through Wednesday)

Questions and comments: