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Application
Which program are you interested in?
*
Which program are you interested in?
A
Infant-Toddler Program
B
Pre-K & Kindergarten
Child's Full Name
*
Child's Date of Birth
*
Home Address
*
Allergies
*
Preferred Schedule
*
Preferred Schedule
A
AM Program (9:00am-12:00pm)
B
PM Program (12:00pm-3:00pm)
C
Extended Day Program (9:00am-3:00pm)
D
Full Day Program (8:00am-6:00pm)
E
Mommy's Day Out Program (Drop-in schedule)
Preferred Schedule
*
Preferred Schedule
A
AM Program (9:00am-12:00pm)
B
PM Program (12:30pm-3:30pm)
C
Extended Day Program (9:00am-3:30pm)
D
All Day Program (8:00am-6:00pm)
Preferred Program Frequency
*
Preferred Program Frequency
A
2-Day Program
B
3-Day Program
C
5-Day Program
Mother's Full Name
*
Phone Number
*
Email
*
Company/Occupation
Father's Full Name
Phone Number
Email
Company/Occupation
Child's Pediatrician
*
Phone Number
*
Address
Emergency Contact
*
Phone Number
*
Address
Email
People permitted to pick-up the child
*
People permitted to pick-up the child
Mother
Father
Other
Other people permitted to pick up the child
Phone Number
Relationship to the child
Preferred Start Date
*
Does your child have any known allergies?
*
Does your child have difficulties with any of the following?
Does your child have difficulties with any of the following?
A
Eyes
B
Ears
C
Speech
D
Behavioral
Special Instructions or Areas of concern:
How did you hear about us?
*
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