Email Address: *

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Father's Name: *

Child's DOB: *

Child's Last Name: *

Years of Membership:

Child's Gender *

Male

Female

Primary Phone Type:

Home

Cell

Other

Second Phone Type:

Home

Cell

Other

New or Returning:

New

Returning

Street Address *

Board Member:

Child's First Name: *

Referred By:

City / Zip Code *

Sibling of:

Second Phone: *

Mother's Name: *

Other

Primary Phone: *

Date and time *

Preschool

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Liberty Tot Lot - 19033 Studebaker Rd - Cerritos, CA 90703 - (562) 265-8805

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