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I wish to place my	Son Daughter
Child's name
Born on
I wish to place my	Son Daughter
Child's name
Born on
in the	Infant Daycare Kindergarten
from this date on
My child has been raised with more than one language	Yes No
Language/s
Mother
Last name
First name
Street, Apt.#
Zipcode, City
Telephone
Fax
E-mail
Father
Last name
First name
Street, Apt.#
Zipcode, City
Telephone
Fax
E-mail