Enroll/Waiting List
Please complete the form to be placed on the Peacox Child Care Waiting List.
Email address *
What is your intent? *
Child's Name *
Your answer
Child's Birth Date *
Your answer
Text Message Number
Your answer
Email Address *
Your answer
Days of Care Needed *
Your answer
Hours of Care Needed *
Your answer
Preferred Start Date *
Your answer
Mother/Guardian's Name
Your answer
Mother/Guardian's Contact Number
Your answer
Father/Guardian's Name
Your answer
Father/Guardian's Contact Number
Your answer
Submit
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