Please fill out the form below for each child. It will help us to care for your child while you are attending Services. We want to ensure that all children have a positive and safe experience. We kindly ask that you put your cell phone on vibrate in case of emergency. If you have any questions please contact the Room Parents: Jenn Hutter Sollod, jennhuttersollod [at] earthlink [dot] net, 919/475-3484 or Emily Matz, emily [at] matzmail [dot] com, 919/649-4163. Thank you.
| Childs’ Name |
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| Childs’ Age |
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| Potty Trained |
Yes / No |
| Change of Clothes |
Yes / No |
| Allergies or Dietary Restrictions |
Yes / No |
| If yes, please detail |
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| Parent/Guardian |
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| Cell Phone # |
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| Parent/Guardian |
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| Cell Phone # |
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| Comments – Please share any special routines, fears or other information that may help your child to have the best possible experience |
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| For Official Use Only |
| Drop off Time |
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Pick up Time |
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| Diaper Change Time(s) |
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