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Visitation Form
Little Heaven Daycare
2020-06-04T00:29:18+00:00
PLEASE FILL THIS FORM BEFORE ARRIVING TO YOUR APPOINTMENT!
Have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days?
YES
NO
2. Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat?
YES
NO
Name
*
First
Last
Email
*
Phone
*
how old is your child/children:
*
when would you like to visit us?
*
MM slash DD slash YYYY
We will call you and confirm the visitation date.
Your Address:
*
Street Address
City
State / Province
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Child’s Name:
*
Day of Birth:
*
MM slash DD slash YYYY
Current Childcare Arrangements, and Reason for needing new childcare:
Start day:
*
Monday
Tuesday
Wednesday
Thursday
Friday
How did you hear about us?
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Email
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