Registration For All Classes 2007 - 2008

Personal Information

Child’s full name_________________ Date of Birth_______________________

Child goes by__________________________

Child's home address____________________________________________

City___________________________State______Zip__________________

Child's home phone number_______________________________________

Parent or Guardian Information

Father’s name______________________ Phone_______________________

Father's address________________________________________________

City___________________________State______Zip__________________

Father's Occupation and place of employment___________________________________

___________________________________________Phone_______________________

Mother’s name______________________ Phone_______________________

Mother's address________________________________________________

City___________________________State______Zip__________________

Mother's Occupation and place of employment___________________________________

___________________________________________Phone_______________________

Personal History

Has your child attended a nursery school before? _______ If yes, please indicate where.______________

Does your child have any allergies?______________________________________________

Are there any medical conditions of which we should be aware?____________________

_________________________________________________________________________________

Is there any additional information about your child of which we should be aware?

_________________________________________________________________________________

Are you a member of a church? ___________ If not, may we send you our church’s newsletter?________

Pick Up

Persons authorized to pick up child

Name_____________________Phone_______________________Car_________________________

Persons who may not pick up child

Name_________________________________________________Car_________________________

In case of emergency, notify_________________________________________________

Classes Available

- Please indicate your first and second choices
Pre-Kindergarten (Children 4 on or before September 30)
______ 5-day class (M-F), 9:00am - 11:30am
______ 3-day class (M,W,F), 9:00am - 11:30am
______ 2-day class (T,R), 9:00am - 11:30am

3-Year-Old-Class (Children 3 on or before September 30)
______ 2-day class (T,R), 9:00am - 11:30am
______ 2-day class (M,W), 9:00am - 11:30am
______ 1-day class (F), 9:00am - 11:30am

2-Year-Old-Class (Children 2 on or before Sept 30th)
______ 1-day class (M), 9:00am - 11:30am
______ 1-day class (R), 9:00am - 11:30am

Class configuration may change according to registration. Classes must meet minimum enrollment requirements in order to operate.

A $35.00 non-refundable registration fee per family is required.