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Child Care Application I
1
Approximate date when you will need child care
*
This field is required.
-
Date
Month
Day
Year
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2
Desired child care slot
*
This field is required.
Full-Time
Part-Time
Drop-In
Seasonal
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3
Approximately what days of the week
*
This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
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4
Does your family have a child care voucher OR is awaiting financial assistance?
If so, please explain. If not, leave blank.
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5
Name
*
This field is required.
First Name
Last Name
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6
Contact Email
*
This field is required.
example@example.com
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7
Contact Phone Number
*
This field is required.
Area Code
Phone Number
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8
Preferred Contact Method
*
This field is required.
Phone
Email
Other
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9
Child's Name
*
This field is required.
First Name
Last Name
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10
Age
*
This field is required.
Enter the date that your child BECAME or WILL BECOME 6 months of age.
/
Date
Month
Day
Year
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11
Child's sex
*
This field is required.
Male
Female
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12
Lastly, how did you hear about us?
*
This field is required.
Care.com
Daycare Services Website
Word of mouth / Personal Referral
Social Media
Internet Search
Flyer or Poster
Online Ad
Other
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13
Please share with us who referred you to us (First & Last name) or how you heard about us.
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14
Application Fee. Non-Refundable
Your spot on our waitlist is secured upon payment of the fee below. Please note that your application is good for ONE calendar year.
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ORDER SUMMARY
Total
USD
Application Fee (Non-Refundable)
$
40.00
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15
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16
Payment Methods
Debit Or Credit Card
Select PayPal Method
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
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the form.
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