Parent / Guardian Name
please enter your full name
*
Phone Number
e-mail address
Type of Care
*
Full-Time
Part-Time
If Part-Time, Which Days:
2-3 days per week
Monday
Tuesday
Wednesday
Thursday
Friday
Drop-Off & Pick-Up Times:
best estimate
From
To
Desired Statr Date
As Soon As Possible
2011 School Year
Other
If other, please select desired start date
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2
1
Day
2010
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Year
1st Child - Please Fill in all Information
Information for First Child
Child's Name
(1)
Child's Age
(1)
Child's Birth Date
(1)
January
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Month
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2
1
Day
2010
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2006
Year
2nd Child - Please Fill in all Information
Information for Second Child
Child's Name
(2)
Child's Age
(2)
Child's Birth Date
(2)
January
February
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April
May
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Month
31
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6
5
4
3
2
1
Day
2010
2009
2008
2007
2006
Year
3rd Child - Please Fill in all Information
Child's Name
(3)
Child's Age
(3)
Child's Birth Date
(3)
January
February
March
April
May
June
July
August
September
October
November
December
Month
31
30
29
28
27
26
25
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22
21
20
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6
5
4
3
2
1
Day
2010
2009
2008
2007
2006
Year
Currently Expecting?
CONGRATULATIONS!
Expected Due Date
-
Month
-
Day
Year
Expected Start Date
-
Month
-
Day
Year
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