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Zia Application

Name *
Name
Phone *
Phone
Home Address *
Home Address
Child's Name *
Child's Name
Child's Date of Birth *
Child's Date of Birth
Must be 1, 3, or 4 days. If you are flexible or unsure please provide all possibilities being considered.
Please describe why you think your child would be a good fit.
Please list the person, organization, or school that cares for your child the majority of time during the day and how happy are you with the current set-up?
Please note there are no right or wrong answers...every child is welcome.
Please highlight favorite foods as well as ones he/she refuses consistently.
Your answer here will help us tailor our curriculum to your child.
Please include circumstances for watching and what programs you allow.
Please select the option most descriptive of your situation.
Please choose the option that best fits your desire.