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First Name^*

Last Name^*

Birthdate^*

Parent/Guardian Name^*

Phone #^*

Email^*

Will you be receiving Government Subsidy for child care?^*

Do you have any children currently enrolled at the center?^*

Are you active member of First Christian Church?^*

(Leave Blank for SUMMER Waitlist) Do you require before/after care for school?

(Leave Blank for SUMMER Waitlist) If your child is in school-age, what school do they attend?

(Leave Blank for SUMMER Waitlist) Does your child need transportation to/from school?

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