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Child's Name* Child's Date Of Birth* Child's Age Group* Caregiver's Name* Relationship to Child* Address* Daytime Contact* Email* Do you require specific days and hours* Yes No Total hours per week* Which Days Monday Tuesday Wednesday Thursday Friday Service Required Full Time Part Time When would you like your child to start? 12 am 01 am 02 am 03 am 04 am 05 am 06 am 07 am 08 am 09 am 10 am 11 am 12 pm 01 pm 02 pm 03 pm 04 pm 05 pm 06 pm 07 pm 08 pm 09 pm 10 pm 11 pm 00 05 10 15 20 25 30 35 40 45 50 55

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