Fill out a Registration Form

 Please include the non-refundable registration fee with completed form.
$125.00 for 1st child $100.00 for 2nd child $75.00 for 3rd child



CHILD’S FIRST NAME_______________LAST NAME____________
D.O.B____________________MALE_______FEMALE________

HOME ADDRESS_________________________________________

_______________________________________________________



FAMILY INFORMATION


 NAME________________________________RELATIONSHIP______
HOME ADDRESS_________________________________________

______________________________________________________
HOME TELEPHONE_________________CELL PHONE_____________

E-MAIL_________________________
EMPLOYER______________________WORK PHONE_____________


NAME_______________________________RELATIONSHIP_______
HOME ADDRESS_________________________________________

______________________________________________________
HOME TELEPHONE_________________CELL PHONE_____________

E-MAIL_________________________
EMPLOYER______________________WORK PHONE_____________
NAME________________________________RELATIONSHIP______


PROGRAM


INFANT (2M-18M)____TODDLER (18M-36M)____

PRESCHOOL (3-5 YRS)___

8 HOURS______ 10 HOURS______ 12 HOURS______

2 DAYS ____ 3 DAYS ____ 4 DAYS ____ 5 DAYS _____


BEFORE/AFTER SCHOOL _____

2 HOURS____ 4 HOURS____ 6 HOURS____ 8 HOURS____


ARRIVAL TIME_______DEPARTURE TIME_______


*****ENROLLMENT IS BASED ON AVAILABILITY*****