Kids Junction, Inc. Fall 2023 Wait List Form
Thank you
for your interest in Kids Junction. We will notify you via email if a spot becomes available.
Child's Name 1
Date of Birth
/
Month
/
Day
Year
Date
Child's Name 2
Date of Birth
/
Month
/
Day
Year
Date
Child's Name
Date of Birth
/
Month
/
Day
Year
Date
Parent/Guardian (1) Name
Parent/Guardian(2) Name
Relationship (1)
Relationship (2)
Street Address (1)
Street Address (2)
Town, State, Zip (1)
Town, State, Zip (2)
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
We rely heavily on email communication. Please list the email or emails you would like
info sent to 1:
info sent to 2:
Days desired Child 1
Mon
Tues
Wed
Thrs
Fri
Days desired Child 2
Mon
Tues
Wed
Thrs
Fri
Start Time
Pick up Time
Starting Date
/
Month
/
Day
Year
Date
School and Grade (if applicable)
Will you need morning transportation from Kids Junction to your child's school?
Who may we thank for referring you?
Parent/Guardian Signature
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: