Last Name/ Apellido _________________________________________

First Name/ Nombre _________________________________________

Address/ Dirección ___________________________________________

City/Cuidad________________________ Zip/Código Postal ____________

Phone/Télefono ________________________  Fax ___________________

Email _______________________________________________________

If you want your name given out for child care referrals,  fill in the following information: Si gusta estar en la lista de referencías, favor de completer lo siguente:

Ages of children/edades de niños su preferencia __________________  

Days of operation/ días abierto  _______________________________

Hours/Horas  ______________________________________________  

Closest School / escuela mas cercano ___________________________

Facility License Number/ Número de Licencia  ___________________

__________________________________________________________

Languages spoken/idíomas hablado 

_____ English _____ Español Other ____________________

How many children are you licensed for?/Licencia Para Cuanto Niños? ____________        

Please check the area you live in:

_____ South Salinas

_____ East Salinas

_____ North Salinas

_____ West Salinas (by Laurel Wood School)

_____ Prunedale/Castroville/

            Watsonville

_____ South County

_____ Monterey Peninsula

DEC