Early Childhood Center Interest Form

If you are interested in having your child attend the St. Lucas Early Childhood Center, please complete the form below and our staff will contact you with additional information as soon as possible.

Parent's or Guardian's Last Name*

Parent's or Guardian's First Name*

Street Address*

City*

State*

Zip Code*

Telephone Number*

Email Address*

Child 1

Last Name*

First Name*

Age (Years)

(Months)

Child 2

Last Name

First Name

Age (Years)

(Months)

Child 3

Last Name

First Name

Age (Years)

(Months)

Extended CareI am interested in Extended Care

Home Church:

Additional Comments or Information:

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