Waiting List Form – Little Smiling Faces Childcare

* Required

Has your child been in childcare before? *

Child's Name *

Child's Date of Birth *

Your Address *

Address Line 1

Address Line 2

City

State

Zip Code

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?