Request More Information
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= REQUIRED
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Child's First Name
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Child's Date of Birth
2nd Child's First Name
2nd Child's Date of Birth
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Program needs by age group:
Infant care - 6 weeks to 16 months
Toddler care - 16 months to 31 months
Preschool for 3's - 31 months to 44 months
Prekindergarten - 44 months to Kindergarten
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When is care needed?
Immediately
Within next 30 days
Within 60 days
Next 3 to 6 months
Next 6 to 12 months (comment below)
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Days of care needed:
Monday
Tuesday
Wednesday
Thursday
Friday
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Type of care needed:
Full-time days
2/3's days (between 5 and 7 hrs/day) start anytime
FT and 2/3's days (comment below)
Drop-in care - Full day
Drop-in care - 2/3's day
Summer only
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Specific needs or requirements? Select all that apply.
None
Food allergies (comment below)
Special needs child (comment below)
Receive county assistance (comment below)
Other (comment below)
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How did you hear about our program? Check all that apply.
Referral (comment below by whom)
Drove by
Website
Web search (comment below which one)
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Yellow pages
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Parent First Name
Parent Last Name
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Your relationship to child/ren:
Mother
Father
Step-Parent
Grandparent
Guardian
Other (comment below
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Parent Phone Number:
-
-
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Parent E-mail Address:
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Best Time to Contact You
Mornings - 8am to 11am
Mid-day - 11am to 1pm
Afternoons - 1pm to 5pm
Evenings - 5pm to 7pm
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Best Way to Contact You:
E-mail
Phone call
Either
Questions and/or Comments:
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