Peacox Child Care Waiting List Form
Child Information
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Family Name (if different from child)
Text Message Contact Number
Potential First Day of Care
Days of Care
Hours of Care
Drop-off Time
Pick-up Time
Parent Information
Mother’s/Parent’s Name
Mother’s/Parent’s Address
Mother’s/Parent’s Phone
Format: (000) 000-0000.
Mother’s/Parent’s Email
example@example.com
Father’s/Parent’s Name
Father’s/Parent’s Address
Father’s/Parent’s Phone
Format: (000) 000-0000.
Father’s/Parent’s Email
example@example.com
Parent’s Signature
Date
/
Month
/
Day
Year
Date
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