First Name

Last Name

Phone Number

Email Address

Anticipated Start Date (MM-DD-YYYY)

Age of Child(ren) Age of Child(ren) Infant (0-11 months) Jr. Toddler (12-18 months) Sr. Toddler (19- 2 years, 11 months) Preschool (3-5 years, not in school) Kindergarten (5-6 years, attending school) Grade 1-6 (6-12 years)

Length of Care Required Length of Care Required Full-Time (3+ days/week) Part-Time (1-2 scheduled days/week) Drop-in (unscheduled days) Summer Care (July and August ONLY)

Waitlist Waitlist I would like to be placed on the waitlist (Fill out form after clicking SUBMIT) I DO NOT wish to be placed on the waitlist (Do not fill out the form after clicking SUBMIT)

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