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Infant program
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Enrollment form
Student information:
First name
Last name
Sex
Birthday
Month
Day
Year
Address
Date of enrollment
Primary Hours of care
From
Time
:
Hours
Minutes
AM
To
Time
:
Hours
Minutes
AM
Days of the week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Family nformation
Mother
Father
Full Name
Full Name
Address
Address
Phone
Phone
Employer
Employer
Work Phone
Work Phone
Multi choice
Mother
Father
Both
Other*
* If Other, Please specify:
Medical Information:
Hospital
Doctor
Address
Phone
Emergency Contacts
Full Name
Phone
Full Name
Phone
By checking this box, i acknowledge
*
Submit
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