02/06/2012
(240)-453-9790
(301)-801-2100

Wait List Form
Lyceum for Kids Daycare

Parent's First Name*:
 Parent's Last Name*:
Street Address*:
City*:
 State*:
 Zip*:
Home Phone*:
 Cell Phone:
e-Mail Address*:
 Work Phone:
Child's First Name*:
 Child's Last Name*:
Date of Birth (mm/dd/yyyy)*:
Childcare Locations:
(Check any of which you would like to attend)		 13544 Glen Mill Road
9 Lakeside Overlook
413 Mercer Rd.
7801 Green Twig Rd.
Attendance Start Date: As Soon As Possible
Approx.Date (mm/dd/yyyy):
Attendance Schedule: Full Time
Part Time (describe):
How did you hear about us?
Comments: