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Child Care Interest Form
Unique Blessings Learning Center, LLC 4851 6th Street, Zephyrhills, FL 33542 NOW OPEN AND ACCEPTING ENROLLMENT FOR INFANT THROUGH VPK & FAMILY READINESS
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* Indicates required question
Email
*
Your email
When do you need child care services to begin?
*
MM
/
DD
/
YYYY
Child care start time
*
Time
:
AM
PM
Child care end time
*
Time
:
AM
PM
How many children do you need care for?
*
1
2
3
4
5
Tutoring- this is at an additional cost from 3-5pm
Yes
No
Summer camp-are you inquiring only for this service?
Yes
No
What ages do you need care for?
*
Infant 0 months-11 months
Toddler 13 months-23 months
3 year old
4 year old
School age
Required
What is the birthdate of the child?
*
MM
/
DD
/
YYYY
What is the birthdate of the child?
MM
/
DD
/
YYYY
What is the birthdate of the child?
Your answer
Is your child under a VPK voucher?
*
Yes
No
Do you qualify for Family Readiness (Early Learning Coalition)-low income family subsidy?
*
Yes
No
I am not sure
Does any of your children have severe allergies to foods?
*
Yes
No
Please leave your name below:
*
Your answer
Please leave your email address below:
*
Your answer
Please leave your contact phone number below:
*
Your answer
Please leave legal guardians name/s?
*
Your answer
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