Just in Time Care Online Enrollment Form

You must be an eligible employee of a Just in Time Care corporate client in order to enroll.

Please fill out the form completely. Please be aware this is a secure form, and all information provided is confidential.

Once we verify your eligibility, we will notify you that your enrollment has been confirmed. If we need additional details to confirm your enrollment, employee ID, or other company required information, we will contact you.

*Fields with an asterisk are required.


*First name: *Last name:
*Home telephone #: (please include area code)
*Home address:
*City: *State: *Zip code:
County:
*Employer:
Work address:
*Street:
*City:
*State:
*Zip code:
*Work telephone #:
Work fax #:
(please include area codes)
*E-mail address:
Employee ID #:
Business unit / zone / cluster:
Name and telephone number of other parent or individual who also might be calling Just in Time Care:
Name: Phone:
*Dependent’s name:
Please select: *Dependent’s date of birth:
Dependent’s name:
Please select: Dependent’s date of birth:
Dependent’s name:
Please select: Dependent’s date of birth:
By submitting this information, I hereby verify that the information provided above is deemed to be correct and true, to the best of my knowledge.
CARE PROVIDER INFORMATION (OPTIONAL) List below care providers you may potentially use for backup care.
Provider name:
Tel. #:
Address:
City:
State:
Zip code:
Provider name:
Tel. #:
Address:
City:
State:
Zip code:
Do you have the full Just in Time Care enrollment packet?
If you do not have the full packet, we will
send your company-specific packet to you.
Do you prefer that the packet be:

By submitting this enrollment form, you indicate your acceptance of the following statement:

With respect to my participation in the Just in Time Care Program, I understand that I will be fully responsible for evaluating the quality, capability, and suitability of a care agency to meet the specific needs and requirements for my dependent. Also, I understand that neither Just in Time Care nor my employer make any representations or warranties regarding the quality, capability, and suitability of a care provider in connection with my participation in the Just in Time Care Program. In consideration for being allowed to participate in the Just in Time Care Program, I agree that Just in Time Care and my employer, its subsidiaries, affiliates, and its and their employees will have no liability, direct or indirect, for the actions of any particular care agency or any adverse consequences that may arise in connection with the use of the Just in Time Care Program.