Patient Portal

Child Care Center Application

* Required

Please confirm the Child's Last Name

Please confirm the Child's First Name and Middle Initial

Please confirm the Child's Date of Birth

Please confirm the Mother's Full Name

Please confirm the Mother's Employer

Please confirm if the Mother is an Employee of PDH

Please confirm the Father's Full Name

Please confirm the Father's Employer

Please confirm if the Father is an Employee of PDH

Please confirm the Mailing address

Please confirm the City

Please confirm the State

Please confirm the Zip Code

Please confirm the Email Address

Please confirm the Mother's Home Phone #

Please confirm the Mother's Cell #

Please confirm the Mother's Work #

Please confirm the Father's Home Phone #

Please confirm the Father's Cell #

Please confirm the Father's Work #

Please confirm the Mother's Email Address

Please confirm the Father's Email Address

Please confirm the Age of Child

Please confirm the Preferred Monthly Child Care Schedule

Please confirm the Days Needed For Care

Please confirm the Specified Hours needed (AM- PM)

Please confirm the Parent/Caregiver Signature

Please confirm the Date

Please confirm the Parent/Caregiver Signature

Please confirm the Date

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