Auntie Em's Daycare
	There's No Place Like Daycare

Child
First Name	Middle Initial	Last Name
Gender   Female Male Unknown	Date of Birth   May 2022 Sun Mon Tue Wed Thu Fri Sat 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec OK Cancel	Your relationship to child   Mom Dad Foster Parent Dentist Guardian Family Friend Neighbor Grandmother Grandfather Aunt Uncle Other Relative Doctor
General Information
When is care needed? (Select One)       Immediately       Within Next 30 days       Next 3 - 6 months       Next 6 - 12 months (Comment below) What programs are needed? (Select All That Apply)       Infant (6 weeks-15 months) part time (1-3 days a week)       Infant (6 weeks- 15 months) full time (4-5 days)       Wobbler (15 - 24 Months) part time (1-3 days a week)       Wobbler (15 - 24 Months) full time (4-5 days)       Little school (2-3 1/2 years) part time (1-3 days a week)       Little school (2-3 1/2 years) full time (4-5 days)       Preschool (3 1/2 - 5 Years) part time (1-3 days a week)       Preschool (3 1/2 - 5 Years) full time (4-5 days)       School age (5-12) Before School Only       School age (5-12) before and after, holidays and summers       School age (5-12) After School Only Days Needed? (Select All That Apply)       Monday       Tuesday       Wednesday       Thursday       Friday       Saturday       Sunday Additional needs or requirements? (Select All That Apply)       Registering more than 1 child       Transportation needed       Subsidized tuition assistance needed       Special needs child (comment below) Is your child a returning student? (Select One)       Yes       No How did you hear about our child care program? (Select One)       Referral       Drove by       Website/Web Search       Yellow Pages
Additional Information (Maximum 500 Characters)
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Emily Stuck, Director 1118 Bond St Lawrenceville, IL 62439 618-707-2244 auntieemsdaycare19@gmail.com