Wait List Form

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Wait List Form

Please complete all sections to the best of your ability

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* Indicates required question

Date *

MM

/

DD

/

YYYY

Parent/Guardian Name *

Your answer

Phone Number *

Your answer

Child's Name (First & Last if available) *

Your answer

Child's Birth Date *

MM

/

DD

/

YYYY

Potty Trained? if applicable

YES

NO

Clear selection

IF School Age: Which school?

Your answer

Sibling Group? *

YES

NO

Approximate Days Schedule *

M

T

Wed

Th

F

Varies

Required

Approximate drop off and pick up times *

Your answer

Applying for Assistance? *

YES

NO

DCFS-Foster Care

Unsure/No answer

Translator Needed? *

YES

NO

Waitlist Submitted By: *

Administration (please initial in NOTE box)

Staff (please initial in NOTE box)

Via Website

NOTE:

Your answer

Submit

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