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Parent/Guardian Name
*
First Name
Middle Initial
Last Name
Primary Contact Number
*
-
Area Code
Phone Number
Alternate Contact Number
-
Area Code
Phone Number
E-mail Address
*
Confirmation Email
Number of Children Needing Care
*
NOTE: If you have more then 2 children you would like to add to the BBDS Wait List please complete and submit this form and then complete and submit a second form.
Child #1
Child #1 Name
*
First Name
Last Name
Child #1 Age
*
0-3 months
3-6 months
6-9 months
9-12 months
12-18 months
18-24 months
24+ months
Child #1 Gender
*
Male
Female
N/A
Desired Start Date
*
-
Month
-
Day
Year
Date
Desired Schedule
*
2-4 days per week (minimum 2 days)
5 days per week
Desired Drop-off Time
*
7:30-8 AM
8-8:30 AM
8:30-9 AM
Desired Pick-up Time
*
3-3:30 PM
4-4:30 PM
5:30 PM
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Next
Child #2
If you have no children needing care at this time, please leave below blank.
Child #2 Name
First Name
Last Name
Child #2 Age
0-3 months
3-6 months
6-9 months
9-12 months
12-18 months
18-24 months
24+ months
Child #2 Gender
Male
Female
N/A
Desired Start Date
-
Month
-
Day
Year
Date
Desired Schedule
2-4 days per week (minimum 2 days)
5 days per week
Desired Drop-off Time
7:30-8 AM
8:30-9 AM
Desired Pick-up Time
3-3:30 PM
4-4:30 PM
5:30 PM
Back
Next
Do You Receive Funding?
*
No funding
Dane County
City of Madison
UW/CCTAP
Other
How Did You Hear About Us?
*
BBDS Parent
Satellite
Friend
Web Search
Facebook
Other
Please verify that you are human
*
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