Care Request

Single choice

5 days/week – Full Time $350/monthly

3 days/week – Part Time $275//monthly

CHILD'S CARE AND SUPPORT INFORMATION

Does the child have any allergies or medical conditions that the program should be aware of?

Does the child require any medication or special health-related support while in care?

Does the child have any additional support needs that may affect participation in the program?

Customer signature

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Parent/Guardian first name

Parent/Guardian last name

Phone number

Event address

Country/Region

Address

City

Zip / Postal code

Child's Full Legal Name

Child'sex

Current School

Child's Date of Birth:

Month

Day

Year

Child's Age