Truks-N-Trykes2 Daycare Center
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Child Care Application for Enrollment
* indicates a required field.

Student Information:

     *Date of Birth:  (Format mm/dd/yyyy)
     *Sex:  Male
Female
    Date of Enrollment:  (Format mm/dd/yyyy)
     *First Name: 
    Middle Name: 
     *Last Name: 
    Nickname: 
    Child's Address: 
    Days of the Week in Care:  Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
    Primary Hours of Care: 

Family Information:

    Child Lives With: 
    Mother's Name: 
    Father's Name: 
     *Daytime Phone Number 

Medical Information:


Contacts:


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