N1Kids - Childcare Information Form

* Required information

* First Name:
* Last Name:
Work Phone:
* Home Phone:
Fax:
* Email:
Location: O'Fallon
Weldon Spring
* Children's names:
* Age of Children: Infant 6wk to 6mo
Infant 6mo to 12mo
1 year
2 year
3 year
4 year
5 year
School age
* Number of Children:
* What type of childcare do you currently use?:
* I am seeking information on (select all that apply): Infant/Toddler Program
Age 2 Program
Preschool Programs Ages 3-5
Kindergarten Before and After-School Program
School Age Before and After-School Program
Summer Programs for all ages
* How did you hear about us?: Sign/Drive by
Telephone Book/Yellow Pages
Newspaper Ad
Friend with child enrolled with us
Local school list of centers
Other
If Other- Please explain:
*security code:  type the characters you see in the picture below: