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ApplicaTION
Please fill out the application below.
Select all programs of interest per child.
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Guardian 1 Information
First Name
*
Last Name
*
Email
*
Cell Phone
*
-
-
Address
*
Use Google Smart Search for Address
Address 1:
City:
Country:
--Select--
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
State/Province:
--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
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Maryland
Massachusetts
Michigan
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Ohio
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code:
Emergency Phone Number
*
-
-
Occupation
*
Workplace name
*
Fully responsible for payments
*
--Select--
No
Yes
Guardian 1: Authorized to pick up Child?
*
--Select--
No
Yes
Guardian 2 Information
First Name
Last Name
Email Address
Cell Phone Number
-
-
Address
Use Google Smart Search for Address
Address 1:
City:
Country:
--Select--
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
State/Province:
--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code:
Emergency Phone Number
-
-
Occupation
Workplace Name
Fully responsible for payments
--Select--
No
Yes
Guardian 2 Authorized to pick up Child?
*
--Select--
No
Yes
Registration Information
Registration Type
*
--Select--
New Client Registration
Returning Client Registration
Returning client: What is your client number?
*
How many new children will you be registering today?
*
--Select--
1
2
3
How many returning children will you be registering today?
*
--Select--
1
2
3
How did you discover LittleLiving?
*
LittleLiving Website
Google search
Bing search
Other web search
Winnie.com
Care.com
Tootris.com
CareLuLu.com
Friend referral
Child 1 Information
Child First Name
*
Child Last Name
*
Date of Birth
*
Gender
*
Is your child fully potty trained?
*
--Select--
No
Yes
Does your child have any Allergies?
*
None
Dairy
Gluten
Chocolate
Nuts
Soy
Fruits
Bees
Hayfever
Asthma
Medication required
Cats
Does your child require medications while at care?
*
None
Asthma Inhaler
Epi Pen
Benadryl
Other
If you marked other medication, write that medication here
Please describe your child's personality, strengths, issues or areas of concern
*
Has your child been in daycare/school outside your home?
*
Child's experience with the outdoors
*
Choose Seasonal Session/s (all of interest)
*
Fall Session Sept - Nov
Winter Session Dec - Feb
Spring Session March - May
Summer Session June - August
AM Session (8:30 a - 11:30a)
Extended Day (8:30a - 4 p)
What days of the week?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Drop In
Requested Start Date?
*
Add Information for Another Child?
Yes
No
Child 2 information
Child 2 First Name
*
Child 2 Last Name
*
Child 2 Date of Birth
*
Child 2 Gender
*
Child 2: Is your child fully potty trained?
*
--Select--
No
Yes
Child 2: Does your child have any Allergies?
*
None
Dairy
Gluten
Chocolate
Nuts
Soy
Fruits
Bees
Hayfever
Asthma
Medication required
Cats
Child 2: Does your child require medications while at care?
*
None
Asthma Inhaler
Epi Pen
Benadryl
Other
Child 2: If you marked other medication, write that medication here
Child 2: Please describe your child's personality, strengths, issues or areas of concern
*
Child 2: Has your child been in daycare/school outside your home?
*
Child 2: Child's experience with the outdoors
*
Child 2: Choose Seasonal Session/s (all of interest)
*
Fall Session Sept - Nov
Winter Session Dec - Feb
Spring Session March - May
Summer Session June - August
AM Session (8:30 a - 11:30a)
Extended Day (8:30a - 4 p)
Please read through the entire website and contact us with any questions to ensure you wish to proceed with registration. Registration is nonrefundable.
Child 2: What days of the week?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Drop In
Child 2: Requested Start Date?
*
Add Information for a 3rd Child?
--Select--
Yes
No
Child 3 information
Child 3 First Name
*
Child 3 Last Name
*
Child 3 Date of Birth
*
Child 3 Gender
*
Child 3: Is your child fully potty trained?
*
--Select--
No
Yes
Child 3: Does your child have any Allergies?
*
None
Dairy
Gluten
Chocolate
Nuts
Soy
Fruits
Bees
Hayfever
Asthma
Medication required
Cats
Child 3: Does your child require medications while at care?
*
None
Asthma Inhaler
Epi Pen
Benadryl
Other
Child 3: If you marked other medication, write that medication here
Child 3: Please describe your child's personality, strengths, issues or areas of concern
*
Child 3: Has your child been in daycare/school outside your home?
*
Child 3: Child's experience with the outdoors
*
Child 3: Choose Seasonal Session/s (all of interest)
*
Fall Session Sept - Nov
Winter Session Dec - Feb
Spring Session Mar - May
Summer Session June - August
AM Session (8:30 a - 11:30a)
Extended Day (8:30a - 4 p)
Please read through the entire website and contact us with any questions to ensure you wish to proceed with registration. Registration is nonrefundable.
Child 3: What days of the week?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Drop In
Child 3: Requested Start Date?
*
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