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Contact Us
After filling the details click on the SUBMIT button.

*indicates required fields 
  *Child's First Name:
  *Child's Last Name:
  *Parents' First & Last Name:
  *Date of Birth:
  *Grade:  Toddler (ages 18 mo - 2)
 Preschool (ages 3 and up)
 Kindergarten Grade
 First Grade
 Second Grade
 Third Grade
 Fourth Grade
 Fifth Grade
  Home Phone Number:
  *Cell Phone Number:
  *Email Address:
  *Gender:  Male
 Female
  *Allergy & Medical Information:
  *Address:
  *City:
  *Zip Code:
  *Emergency Contact (if parent is unreachable):
  *Emergency Contact phone number:
  *Do you regularly attend a church?:  Yes
 No
  If so, where?:
  *How did you hear about Parent's Day Out?:

After filling the details click on the SUBMIT button.
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