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For general information or questions about our Child Care Centers, call or email us and we will be glad to assist you.

Childcare Information Form

First Name:
Last Name:
Work Phone:
Home Phone:
Fax:
Email:
I'm Interested In:
		Children's names:

		Age of Children:
		Infant 6wk to 6mo Infant 6mo to 12mo 1 year 2 year 3 year 4 year 5 year School age
		Number of Children:

		What type of childcare do you currently use?

		I am seeking information on (select all that apply):
		Infant/Toddler Program Age 2 Program Preschool Programs (Ages 3-5) Kindergarten, Before and After-School Program School Age, Before and After-School Program Summer Programs (For all ages!)
		How did you hear about us?
		Sign/Drive by Telephone Book/Yellow Pages Newspaper Ad Friend with child enrolled with us Local school list of centers Other

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