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First Name

Last Name

Gender:

Birthdate:

Soc. Sec. #

Home Phone:

*Contact Email:

Address:

City:

State:

Zip:

Child's Name

Family Name/Nickname:

Gender:

Birthdate:

Home Phone:

School:

Grade Level

Before/After School Transportation Needed? YesNoUnsure

School Address:

City:

State:

Zip:

Local Emergency Contact:

Relationship to child(ren)

Address:

City:

State:

Zip:

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Please list all other children in the household, in order of birth.

Name:

Relation:

Gender:

Birthdate:

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Has either parent been DivorcedSeparatedPreviously Married

Custody Arrangements:

People restricted from child(documented):

Primary language used in the home:

Other languages used:

Most recent daycare/sitter:

Phone:

Reason for Leaving:

What activities does your child enjoy sharing with other family members?

Favorite toys and activities:

Preferred Indoor Activities:

Preferred Outdoor Activities:

List your child's favorite companions (real or imaginary)

Any other interests, concerns, and/or fears that your child has:

What is your primary form of discipline?

How did you hear about us?

Copy of Driver's License/ ID card

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Please list all other children in the household, in order of birth.

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