Enrollment Form

Please fill out the form below to place your child on the waiting list. We will contact you in the event that there is an opening close to your requested date. If you are registering multiple children please complete a form for each child.

* indicates required field

Child's Information

Parent's Information

Contact Information

Additional Information

Click HERE to view/download the "Child Enrollment and Health Information Form".

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    "The Premier Daycare Center for
    Early Language and Reading in Licking County"