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RayCam Licensed Childcare Waitlist Intake Form
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Name of Child *
Child's Date of Birth *
Parent/guardian's name
Primary address for the child
Phone number for the primary guardian/parent *
Email for primary parent/guardian(if preferred to be contacted via email)
Is this waitlist request for daycare or out of school care? *
If for OSC which school does the child attend?
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Is the family connected with any programs in the neighborhood? Check all that apply *
Does the child have any extra developmental or behavioral needs? *
What is the reason for care? If the child has two parents/guardians please note the reason for care for both referral? whether each parent/guardian is working, studying, looking for work or has a medical condition? Or do you have a social worker referral? *
Is there anything else you would like for us to know?
Name of person filling out this form  *
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