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ECC Waiting List
Thank you for applying for child care at our center. We will notify you as soon as we have an opening for your child. Completion of this form does not guarantee that your child has been enrolled in the Employee Child Care Program.
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* Indicates required question
Email
*
Your email
Child's Name (First, Middle and Last)
*
Your answer
Name Child is Called
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
I am interested in enrolling my child for
*
Full Time (Monday-Friday)
Part Time (Mon, Wed, Fri)
Part Time (Tues, Thursday)
Required
My Preferred Location is:
*
Baxter Primary
Prescott South
First Available
First-day child care is needed
*
MM
/
DD
/
YYYY
Legal Parent/Guardian #1 Name (First and Last)
*
Your answer
Legal Parent/Guardian #1 Place of Employment.
If parent is a Putnam County Employee please list location and position.
*
Your answer
Legal Parent/ Guardian #1 Home Phone
*
Your answer
Legal Parent/Guardian #1 Work Phone
*
Your answer
Legal Parent/Guardian #2 Name (First and Last)
*
Your answer
Legal Parent/Guardian #2 Place of Employment.
If parent is a Putnam County Employee please list location and position.
*
Your answer
Legal Parent/Guardian #2 Home Phone
*
Your answer
Legal Parent/Guardian #2 Work Phone
*
Your answer
A copy of your responses will be emailed to the address you provided.
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