Wait List

Child’s Name (Last, First, Middle) (required)

Date of Birth or Expected Due Date(required)

Desired Date of Enrollment(required)

Information About Family

Mother’s Name and Address

Mother’s Telephone and Email Address

Mother’s Employer

Father’s Name and Address

Father’s Telephone and Email Address

Father’s Employer

Information About Child

Has your child been in child care before? Yes O No O

Does your Child have any known allergies? Yes O No O If yes please list

Does your child have any chronic illness or condition ? Yes O No O If yes please list

Please give any information concerning your child’s general health or personal history that would be helpful in their experience in a group setting (examples fears, unique behaviors, characteristics, etc.)

What days do you need care?

(required) Full time (Monday through Friday)

Monday/Wednesday/Friday

Tuesday/Thursday

First Available

Date (required)

Information About Family

Information About Child

What days do you need care?

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