----------------------------- Early Childhood Registration Form -----------------------------
Student First Name
*
Student Last Name
*
Date of Birth
*
Address1
*
Address2
City
*
State
*
Zip
*
Telephone
*
Cell Phone
Email
*
Parent/Guardian Name
*
Emergency Contact
*
Emer. Contact Telephone
*
Name of Current School
Special Health Conditions (if any, please explain)
Dietary Restrictions (if any, please explain)
Registering For:
Sessions
*
Session 1 (June 15 thru June 26)
Session 2 (June 29 thru July 10)
Session 3 (July 13 thru July 24)
Session 4 (July 27 thru August 7)
Blocks
*
Full Day (8:00am – 6:00pm)
Moring Block (8:00am - 11:30am)
Afternoon Block (12:00pm - 3:30pm)
Late Afternoon Block (3:30pm – 6:00pm)
Would you like school provided lunch?
*
Yes
No
Would you like school provided transportation?
*
Yes
No
Payment Type
Check
MasterCard
Visa
Credit Card Number
Exp. Date
Comments
