Application for Enrollment
A $25 fee is required to be put on the waiting list.
If child is enrolled within 30 days of this application,
fee will be applied to $75 Registration Fee.
(Please print or type)
Date: ______________
Parent's Name(s): _______________________________________________________
Street Address: _________________________________________________________
City, State, Zip: _________________________________________________________
e-mail address: _________________________________________________________
Home Phone Number: ___________________________________________________
Mother's Work Phone: _______________ Father's Work Phone:__________________
Child's Name: _________________________________________________________
Age: ___________________ Birthdate: _________________ MALE or FEMALE
Date space is needed: ___________________________________________________
Schedule requested: ______ 5 days per week (full time)
______ 3 days per week (M/W/F)
______ 2 days per week (T/Th)
Parent's Signature: _____________________________________________________
A $75 non-refundable registration fee per child is required
when an opening is offered and accepted.
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