Waiting List Application
Child's Name *
Your answer
Child's Birthday *
MM
/
DD
/
YYYY
Gender *
Parent(s)/Guardian(s) *
Your answer
Home Address *
Your answer
Home/Cell Phone *
Your answer
Email Address *
Your answer
Mother Employer
Your answer
Mother Employer Phone
Your answer
Father Employer
Your answer
Father Employer Phone
Your answer
Potty Trained? (any that apply)
Have they been in group care before?
Last daycare or provider
Your answer
Last daycare or provider phone
Your answer
Comments/reasons for leaving your last care environment
Your answer
I need care by *
MM
/
DD
/
YYYY
Does your child have any special requirements such as food substitutions or allergies?
Your answer
Additional Notes
Your answer
Recommended by
Your answer
Acceptance of Information
Please type your full name below, showing that you agree the above information is correct. If you have any questions, please contact us at (580) 223-4807. You will be contacted within 3 to 5 business days after receiving your application.
Signature (your full name) *
Your answer
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