after-school form - Family Space

Gender *

Name *

First

Last

Address for billing

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

ℹ In case the address for service delivery is different, we shall welcome if you can share it in "Comments" bellow.

Email *

Phone

add your country code (Ex: +33 for French numbers)

Are you ( will you be) tax payer in France? *

Yes
No

ℹ Usefull in case of eligibility to the benefits (see here)

Are you ( will you be) afiliated to the French social security system? *

Yes
No

ℹ Usefull in case of eligibility to the benefits (see here)

Number of children *

Single mother

Single mother

Name of the first child

Birth date first child *

Name of the second child

Birth date second child *

Name of the third child

Birth date third child *

Name of the fourth child

Birth date fourth child *

If you have more than 4 children, please mention this in the comment below.

Weekly schedule expected

Monday

Monday:

Start time (Monday):

End time (Monday):

Tuesday

Tuesday:

Start time (Tuesday):

End time (Tuesday):

Wednesday

Wednesday:

Start time (Wednesday):

End time (Wednesday):

Thursday

Thursday:

Start time (Thursday):

End time (Thursday):

Friday

Friday:

Start time (Friday):

End time (Friday):

Wish for the start date *

Income range:

ℹ useful for families eligible for social and tax benefits

How did you know about Family Space?

Please tell us more about it

Comments

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry. *

After-school pick up

Your quote for an after-school pick up

Weekly schedule expected