* Required Please enable JavaScript in your browser to complete this form.Has your child been in childcare before? *YesNoChild's Name *Child's Age *18 month old to 23 months2 years old3 years old4 years old5 years oldChild's Date of Birth *Your Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Mother's Name *Mother's Work Number *Mother's Cell NumberMother's EmailFather's Name *Father's Work Number *Father's Cell NumberFather's EmailWhen would you like your child to start at LSFDC? *Approximate DateAre there any special needs or things we should be aware of concerning your child?(i.e. hearing or speech impaired or medication regularly given for a specific condition)Questions or Comments:Is there anything else you want to add?Submit