Order Form- Basic Listing

Please print off this form, fill in the information below and send along with cheque for $ 25.00  made out to Eryn Wiedner and mail to us at PO Box 75225, White Rock, BC, Canada  V4B 5L4. If you have questions please call us at (604) 614-7990.
** Pricing Information click here
** Please note: for the Premium Listing option ($40 per year)  please click here

REQUIRED PROVIDER INFORMATION (Please fill in as much information as possible. Please print clearly)

FACILITY NAME _____________________________________________________________________________________

CONTACT PERSON _________________________________________________________________________________

OWNER/ MANAGER NAME ___________________________________________________________________________

LOCATION (CIVIC ADDRESS) _________________________________________________________________________

MAILING ADDRESS _________________________________________________________________________________

PHONE (           )  __________________________

FAX (         ) ______________________________

EMAIL _____________________________________  

AGES OF CHILDREN ______________________________

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