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    CHILDS NAME (FULL) ____________________________________________________________________
     
    ******Name to which your child is accustomed ____________________________________________________________
     
    CHILDS BIRTHDAY _________________________________
     
    MOTHERS NAME ________________________________
    FATHERS NAME _________________________________
     
    MOTHERS ADDRESS ____________________________
    FATHERS ADDRESS ______________________________
     
    PHONE (day)________________ (eve) ___________
     
    HAS YOUR CHILD ATTENDED ANY OF THE FOLLOWING: ________
     
    NURSERY SCHOOL/PLAYSCHOOL ________  HEAD START
     
    NUMBER OF YEARS ________ LOCATION __________________________
     
    ________CHILDCARE _________OTHER
     
    NAME, ADDRESS, AND TELEPHONE NUMBER OF AFTER-SCHOOL BABY SITTER:
     
    What would you like me to know: