Registration Form

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Registration & Waiting List Form

Child Information

Child's Last Name

First Name

M.I.

Date of Birth

Gender

Male

Female

Desired Start Date

Parent / Guardian Information

Parent / Guardian 1

Full Name

Relationship to Child

Home Address (if different from child)

Cell Phone

Work Phone

Email Address

Parent / Guardian 2

Full Name

Relationship to Child

Cell Phone

Work Phone

Email Address

Program Interest

Program Type:

Infant

Toddler

Preschool

Pre-K

School Age

Days Requested:

Monday

Tuesday

Wednesday

Thursday

Friday

Emergency Contact (Authorized Pick-up)

Name

Relationship

Phone Number

I certify that the information provided above is accurate. I understand that completing this form does not guarantee enrollment and implies a request for placement on the waiting list if space is unavailable.

Parent / Guardian Signature

Date

FOR OFFICE USE ONLY

Date Received:

Reg. Fee Paid:

Start Date: