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Get Daycare Intake Form 2012-2024

Irth: ___________ Child’s age in months: __________ Family’s Ethnic Background: African American White Gender of Child: Hispanic Male Female American India/Alaskan Native Asian/ Pacific Islander English Primary language in the home: Other: ____________________________________ Other: ____________________________________ Spanish Home Address: ____________________________________________________________ Zip Code: __________ Parent Primary Phone Number: ________________________ Secon.

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