Wait List Registration Form

1

Please complete this form if there are no current openings or you would like to wait for a future childcare spot.

2

Child's Name* This field is required.

First Name

Last Name

3

Gender* This field is required.

Female

Male

4

Child's Birth Date

Date

5

Is your child immunized?* This field is required.

Yes

No

6

Has your child been in daycare before?* This field is required.

Yes

No

7

Does your child have any medical conditions?* This field is required.

8

Does your child have any allergies?* This field is required.

Yes

No

9

If yes please list, including any food or drug allergies.

10

Does your child require any medication? If yes, please list these medications.* This field is required.

11

Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

12

Parent/Guardian 1* This field is required.

First Name

Last Name

13

Home Phone* This field is required.

14

Cell Phone* This field is required.

15

Work Phone* This field is required.

16

E-mail* This field is required.

example@example.com

17

Parent/Guardian 1 (if address is different than child's)

Street Address

Street Address Line 2

City

State

Zip Code

Country

18

E-mail* This field is required.

example@example.com

19

Parent/Guardian 2* This field is required.

First Name

Last Name

20

Cell Phone* This field is required.

21

Home Phone

22

Work Phone* This field is required.

23

Comments

24

Expected Departure Date (if any)

Date

25

Expected Start Date* This field is required.

Date

26

What days of the week are you looking for care?* This field is required.THE DAYCARE IS CLOSED ON MONDAYS

Tuesday

Wednesday

Thursday

Friday

27

Were you referred by anyone?* This field is required.

28

Parent/Guardian 2 (if address is different than child's)

Street Address

Street Address Line 2

City

State

Zip Code

Country

29

How long are you willing to wait for a spot to become available?* This field is required.

30

Hours of Care* This field is required.

Start Time

Until

Pick Up Time

31

Please contact us if you have any questions about the Waitlist Registration.

Email: info@babybeardaycare.org

Phone: 978-703-3853