Childcare Center Pre-Registration Form

Childcare Center Pre-Registration Form
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Please fill out this pre-registration form to be considered for one of our infant or toddler full and part-time spaces. After this form is submitted, we will contact you to schedule an interview to meet your lovely family! We will discuss your childcare needs and our philosophy.
Parent #1 Name
First NameLast Name
Parent #2 Name
First NameLast Name
Child's Name
First NameMiddle NameLast Name
Child's Birth Date
MonthDayYear
Child's Gender
Address
Street Address
Street Address Line 2
CityState
Zip Code
Primary E-mail
example@example.com
Secondary E-mail
(optional)
Preferred Start Date
Parent #1 Primary Phone Number
Format: (000) 000-0000.
Parent #2 Primary Phone Number
Format: (000) 000-0000.
Preferred Care Schedule
Exceptional Childcare Needs
Additional Comments
If not full-time, please indicate preferred schedule.
Should be Empty:

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