top of page
bgImage

ENROLLMENT

Please fill out the form below

Your Full Name/Spouse's full name if applicable*

Children's Names & Ages*

Email Address*

Home Address*

Parent Contacts*

Additional Emergency Names & #s*

Special Needs*

Date Selector*

Time Selector*

Please provide Reason for care needed and any further Info pertinent to your child*

Under His Wings may transport my child for events, every day travel, and emergency situations. *

May we use photos of your child in our newsletters to supporters?*

By checking this box I agree Under HIS Wings Community Center, Inc., its staff, respite care providers, board members, nor their family members, are not responsible for accidental injury, loss of limbs, accidental death, or natural disasters. I also agree that unless I notify Under HIS Wings beforehand, if I do not pick up my child or children as agreed, local authorites will be notified. *

How did you hear about us?*

Electronic Signature*

Fees/Donations

per child

Self Pay Discounted



 Available Scheduling

Times Available Throughout the Week Available Per Scheduling

$50.00

Evening Respite

6pm - 11:00pm

$150

Full Day

24 Hr. Period

$60.00

Overnight Care

7:00pm - 8:00am

$750.00

5 Full Days / 5 Full Nights

Sunday Night - Friday Evening

$1050.00

7 Full Days / 7 Full nights

Any Subsequent 7 Nights and Days

$35.00 Hourly

Short Term Emergency Placements

2hr. Min Flat Rate As Available

$10.00 OFF

Any Time

2nd child w/special needs

Discounted Rate

TBD

Any Time

Sibling w/o Special Needs

Depends on Days, times & Avaiability

$ .40 per mile

+ gas 

Travel Expenses

*All Special Financial Circumstances will be considered as funds are available*

Thanks for allowing us to serve your family!

Mileage is additional for Pick-up, Drop-off, and any additional travel. Gas is included in fees unless travel is more than 25 miles.

Donations are tax deductible

501(c)3

Under HIS Wings CC, Inc. Web Designer - Cindy Millsap Copyright ©2021

bottom of page