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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

*

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)

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 difficulties with any of the following?

A

Eyes

B

Ears

C

Speech

D

Behavioral

Application

Which program are you interested in?

Child's Full Name

Child's Date of Birth

Preferred Schedule

Preferred Schedule

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

Other people permitted to pick up the child

Phone Number

Relationship to the child

Preferred Start Date

Does your child have difficulties with any of the following?

Special Instructions or Areas of concern: