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milestoneslearning
2019-05-23T17:33:10+00:00
Child's Name (Last, First, Middle)
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Date of Birth or Expected Due Date
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Desired Date of Enrollment
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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?
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Full time (Monday through Friday)
Monday/Wednesday/Friday
Tuesday/Thursday
First Available
Date
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