Bellingham Childcare & Learning Center

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Waiting List

Child's Name:
Birthdate:
Address:
Mother's Name:
Home Telephone:
Employer's Name:
Employer's Telephone:
Father's Name:
Home Telephone:
Employer's Name:
Employer's Telephone:
Requested Enrollment Date:
Referred By:
Days and Times Needed:
Monday
Tuesday
Wednesday
Thursday
Friday
E-mail Address:
E-mail me a copy

Please fill in all fields. Type "none" for unknown information.

Payment Type:
Reason for Care:
Today's Date:
Parent Signature:

(Typing your name above serves as your signature)

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Bellingham Childcare & Learning Center · 2600 Squalicum Parkway · Bellingham, WA. 98225 · 360.676.0950

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