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.