*Parent's Full Name:

*Email Address:

*Phone Number:

Address:

*City:

*State & Zip:

Child's  Name:

*Child's Birth date (MM/DD/YYYY):

Current Age:

Is your child Potty Trained?

Yes No

Does your child use pacifier ?

Yes      No   

Is your child on bottle ?

Yes No

Which service are you
interested in?:

Type of Care Full-Time Care Part-Time Care Drop-In Care Before School After School Care Before & After School

 * Hours care is needed:

 Example:7- 4 PM or 8-5 PM

Estimated date childcare needed?

Do you need transportation to school?

Which school does you child attends ?

School Attends White Elem.( Wichita ) Cessna Elem. ( Wichita) Ruth Clark Elem. ( Haysville) Freeman Elem. ( Haysville) Prarie Elem. ( Haysville) Nelson Elem. ( Haysville) Rex Elem. ( Haysville)

School not listed? Ask might transport ?

Days care is needed:

 M, T, W, Th or Fr

Additional Comments:

Who referred you to my daycare ? Or where did you hear about? What website or search engine, sign or agency?

 Thank you!!