Childcare Center Pre-Registration Form

Childcare Center Pre-Registration Form
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Please fill out this pre-registration form to be considered for one of our infant or toddler full and part-time spaces. After this form is submitted, we will contact you to schedule a tour to meet your lovely family! We will discuss your childcare needs and our policies.
Parent #1 Name*

First NameLast Name
Parent #2 Name

First NameLast Name
Child's Name*

First NameMiddle NameLast Name
Child's Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary E-mail*
example@example.com
Preferred Start Date

MonthDayYear
Date
Parent #1 Primary Phone Number
Parent #2 Primary Phone Number
Preferred Care Schedule*
Exceptional Childcare Needs
Additional Comments
If not full-time, please indicate preferred schedule.
Signature

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Child's Gender*
Secondary E-mail
(optional)
Should be Empty:

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