Child's name
Date of Birth
Age
Sex
Race (optional)
Days/Hours of Care Needed
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Mother/Guardian's Name Date of Birth Cell Phone # Home Phone # Address Employer Work Phone # Days/Hours Email Address --- Father/Guardian's Name Date of Birth Cell Phone # Home Phone # Address Employer Work Phone # Days/Hours Email Address --- Legal Guardian Person/Agency with Custody --- Marital Status —Please choose an option—SingleMarriedSeparatedDivorced Number in Household Annual Gross Family Income (verification of income will be required at time of enrollment)
