| Child's Name | ________________ | _______________ | ______________________ | _____________ |
| First | Middle | Last | Nickname |
Male Female Birthdate: month____________ day____________ year_________
| Child's home address | ___________________________ | __________________ | ______________ |
| street address | city | postal code |
Phone Number: ________________________
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Mother's name: __________________________ Phone: same as child's
or ____________
Address: same as child's or: ____________________________________________________
Occupation: ______________________________________________
Place of work: address: __________________________________________________________
Work phone number: _______________________ Cell phone: _________________________
Father's name: ___________________________ Phone: same as child's
or ____________
Address: same as child's or: ____________________________________________________
Occupation: ______________________________________________
Place of work: address: __________________________________________________________
Work phone number: _______________________ Cell phone: _________________________
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Previous pre-school experience: __________________________________________________
Siblings -- names and ages: ______________________________________________________
FEES: $10 Registration Fee per family
| Fee for Weeks 2, 4, 5, 7 & 8: | $100 |
| Fee for Week 3 (Kids in the Kitchen): | $110 |
| Fee for Week 1, 6 (4-day weeks): | $  80 |