SELIS Daycare Waitlist

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Parent/Guardian Name *

First

Last

Child's Name

First

Last

Parent/Guardian full-time Child's

Parent/Guardian Email *

Parent/Guardian Phone *

Preferred Start Date *

What is your preferred start date?

Does your child have any medical conditions? *

or require any special accommodations?

Are you seeking full-time or part-time care? *

Do you require extended hours? *

(early drop-off or late pick-up)

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