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Contact Form
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1
Parent/Guardian's Name:
*
This field is required.
First Name
Last Name
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2
Child's Name:
*
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First Name
Last Name
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3
How Old is Your Child?
*
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4
What is your child's date of birth?
*
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-
Date
Month
Day
Year
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5
Phone Number
*
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Phone Number
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6
What date would you like to start care?
*
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-
Date
Month
Day
Year
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7
Your E-mail Address:
*
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example@example.com
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8
Does your child have any allergies? If so, please list.
*
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9
Are you a teacher? If so, do you plan to take a summer absence?
*
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10
Which Days Do You Need For Care
*
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We are closed on Mondays
Tuesday
Wednesday
Thursday
Friday
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11
Drop off and Pick Up Time
*
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Minutes
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12
Has your child been in daycare before?
*
This field is required.
Yes
No
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13
How did you hear about us?
*
This field is required.
Referred by a Friend
Internet Search
EEC Referral
Other
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14
Prefered Contact?
*
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E-mail
Phone
Text
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15
Questions or Comments:
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16
Please note: Visits to the Daycare are by appointment only.
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