Waiting List Form

* Required

Location *:
 Little Smiling Faces Daycare Center (Upper Marlboro) Little Smiling Faces Daycare Childcare Center II (Mitchellville)

Is Your Child a Perrywood Resident *:
 Perrywood Resident Non-Perrywood Resident

Child's Name *:

Child's Age *:
 18 month old to 23 months 2 years old 3 years old 4 years old 5 years old

Child's Date of Birth *:

Your Address *:
(Full Address w/City, State and Zip)

Home Phone *:

Mother's Name *:

Mother's Work Number *:

Mother's Cell Number:

Mother's Email:

Father's Name *:

Father's Work Number *:

Father's Cell Number:

Father's Email:

When would you like your child to start at LSFDC *:
(Approximate Date)

Are there any special needs or things we should be aware of concerning your child?
(i.e. hearing or speech impaired or medication regularly given for a specific condition)

Questions or Comments:
Is there anything else you want to add?