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Name of Parent or Guardian *
Name of Parent or Guardian
Address *
Address
Phone
Phone
Child's Name 1 *
Child's Name 1
Birthday 1 *
Birthday 1
Child's Name 2
Child's Name 2
Birthday 2
Birthday 2
Child's Name 3
Child's Name 3
Birthday 3
Birthday 3
Checkbox *
Choose specific days your child/ren will be attending. ($50 per day-one child; $40 per day-two or more children)
Name
Name
Emergency Contact
Phone Number
Phone Number
Name *
Name
Children's Primary Care Physician
Phone *
Phone
$10 per child- before care; $15 per child- after care until 5:30. List any days you would like to send your children to extended day. Please specify before care or after care.
Method of Payment *
Payment is required for registration. If you do not hear from us within two days of submitting this application, please call 504-456-6429.