Child's Day Wait List Request

Child's Day Wait List Request

Thank you for your interest in Child's Day. Please complete this form to be placed on our wait list. There is a $75 per family fee to be placed on the wait list.
Child's Name (enter "Baby" if undecided)

First Name Last Name
Birth Date or Due Date

Month Day Year
Date
Gender
Do you have another child you need to add to the wait list?
Child's Name (enter "Baby" if undecided)

First Name Last Name
Birth Date or Due Date

Month Day Year
Date
Gender
Parent 1 Name

First Name Last Name
Parent 1 Email
example@example.com
Parent 1 Phone Number

Area Code Phone Number
Parent 1 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent 1 Employer
Parent 1 Occupation
Parent 1 Work Phone Number

Area Code Phone Number
Parent 2 Name

First Name Last Name
Parent 2 Email
example@example.com
Parent 2 Phone Number

Area Code Phone Number
Parent 2 Address (If Different from Parent 1)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent 2 Employer
Parent 2 Occupation
Parent 2 Work Phone Number

Area Code Phone Number
Our/My preference is to start:
If other, please specify
We/I would consider starting:
If other, please specify
I heard about the center from
If other, please specify
Do you know any current Child's Day families? If yes, please list their name below.
Is there anything else you'd like to share with us about your family or your child?
Signature - I understand submitting a wait list form and fee does not guarantee enrollment.

Clear
Name of Person Completing Form

First Name Last Name
Today's Date

Month Day Year
Date

My Products

Wait List Fee $ 75.00

Enter coupon

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