Child Care Online Registration

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Choose a program

Toddler Program   Preschool Program    Pre-K Class   School Age Summer   School Age Before and/or After School

Child Last Name: Child First Name: Sibling

Address  

City     Zip 

Birthdate  

Gender     
 Female    
 Male

School  

Grade Fall 2005

Mother's Name  

Fathers Name  

With whom does the child reside?     

 Mother   
 Father
 Both  
 Other  

Home #      
Work #   
Cell #  

Best # to call : 
 Home  
 Work  
 Cell

Best time to call : 

 Morning
 Afternoon  
 Evening

Questions or comments
 

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