Waiting List Form

* Required

    Location *:
    Little Smiling Faces Daycare Childcare Center II (Mitchellville)

    Is Your Child a Perrywood Resident *:
    Perrywood ResidentNon-Perrywood Resident

    Child's Name *:

    Child's Age *:
    18 month old to 23 months2 years old3 years old4 years old5 years old

    Child's Date of Birth *:

    Your Address *:
    (Full Address w/City, State and Zip)

    Home Phone *:

    Mother's Name *:

    Mother's Work Number *:

    Mother's Cell Number:

    Mother's Email:

    Father's Name *:

    Father's Work Number *:

    Father's Cell Number:

    Father's Email:

    When would you like your child to start at LSFDC *:
    (Approximate Date)

    Are 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?