Form

Camp & Schools Out Program Request Form

Tell us about yourself:

Employee First Name*

Employee Last Name*

Work Email*

Phone Number*

Company*

Second Parent/Guardian First Name

Second Parent/Guardian Last Name

Second Parent/Guardian Company

Street Address*

City*

State*

Zip Code*

Example: 10013

Country/Region

Child 1 First Name*

Child 1 Birthdate*

Month/Day/Year

Child 2 First Name

Child 2 Birthdate

Month/Day/Year

Child 3 First Name

Child 3 Birthdate

Month/Day/Year

When do you need care?

Date 1*

Month/Day/Year

Care Start Time 1*

Care End Time 1*

Time Zone 1*

Date 2

Month/Day/Year

Care Start Time 2

Care End Time 2

Time Zone 2

Day 3

Month/Day/Year

Care Start Time 3

Care End Time 3

Time Zone 3

Day 4

Month/Day/Year

Care Start Time 4

Care End Time 4

Time Zone 4

Day 5

Month/Day/Year

Care Start Time 5

Care End Time 5

Time Zone 5

If a colleague referred you to Vivvi, please share their name below!

Health and Safety Protocols*

Vivvi Backup Care cannot be provided for a child experiencing contagious illness (i.e. COVID-19) or symptoms of fever (100.4 or higher), vomiting or diarrhea.

Vivvi Backup Care cannot be provided for an individual experiencing contagious illness (i.e. COVID-19) or symptoms of fever (100.4 or higher), vomiting or diarrhea.

At this time, my child is not experiencing any illness or symptoms that would prevent Vivvi from booking backup care.

If my child becomes ill prior to the booking, I will contact Vivvi at backup@vivvi.com.