Check Slot Availability
Guardian's Name
*
I'm interested in enrolling children in the following age ranges:
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0-1 years
1-2.5 years
2.5-3 years
3-4 years
4-6 years (Not in school)
5+ years (in school)
Please include all birthdays below, for children you would like to enroll.
Child 1 Birthday
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Month
-
Day
Year
Date
Child 2 Birthday
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Month
-
Day
Year
Date
Child 3 Birthday
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Month
-
Day
Year
Date
Child 4 Birthday
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Month
-
Day
Year
Date
Child 5 Birthday
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Month
-
Day
Year
Date
Are the children you would like to enroll potty trained?
*
Please use the child number from above to let us know which child(ren) is/are potty trained. For Example: 1,3,5.
Preferred Method of Communication?
*
Phone Call
Text Message
Email
Do you have CCAP Assistance?
*
Yes, CCAP will be helping me pay for care
No, I am not using CCAP assistance
I do not have CCAP assistance now but hope to in the future
Unsure
Preferred Start Date
*
-
Month
-
Day
Year
Put your ideal start date or best guess if you are unsure.
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Message
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