* = Required Information
Today’s Date
*
Requested Starting Date
*
Child’s Last Name
*
First Name
*
Child’s Date of Birth
*
Gender
Male
Female
Home Address
City
State
Zip
Home Phone No
Alternate Phone No
Please (tick) from the following programs:
FULL DAY 8:00 AM - 6:00 PM
SCHOOL DAY 9:00 AM - 4:00 PM
MORNING SESSION 9:00 AM - 12:00 PM
AFTERNOON SESSION 2:00 PM - 5:00 PM
Mother’s Name
Employer Name
Cell Phone
Work Phone
E-Mail
Father’s Name
Employer Name
Cell Phone
Work Phone
E-Mail
**All enrollment applications are subject to approval and space is not guaranteed until a $100.00 registration fee has been paid, and enrollment application has been signed.
Parent 1 Signature
Parent 2 Signature
Date
Submit