(Please print or type.)                                                                                        Birth Date: _____ /______/____

Childís Name: ____________________________________________________ Nick Name:_____________
                           (Last)                                                 (First)                                       (MI)
Address:__________________________________________ Town: ____________________ Zip:________

Home Phone No. (____) ______-_________ Cell Phone:(_____) _____-__________ E-Mail:____________

Fatherís Name: _______________________________ Motherís Name:_____________________________

Sisterís, Brotherís & Ages:_________________________________________________________________

Fatherís Work Place: _____________________________________________ (____)____ -___________
                                                     (Name, Address, Phone Number)
Mother Work Place:_______________________________________________ (____)___ -_____________
                                                    (Name, Address, Phone Number)
Emergency Name: _____________________ Phone: No.(____)_____ -_______ Relationship:_____________

Pediatrician: ___________________________________________ Phone No. (____ )______ -___________

Address: ________________________________________ Town: _____________________ Zip:________

Physical Limitations and/or Allergies: __________________________________________________________

® I authorize my child to be taken to ___________________________ hospital in case of an emergency

o  Monday                                                                        o A.M. Session (9:00 am to 11:30 am)
o Tuesday                                                                         o P.M. Session (1:00 pm to 3:30 pm)
o Wednesday                                                                    o Full Day (7:00 am to 6:00 pm)
o Thursday                                                                        o Extended Day (________ hours)
o Friday
o Full Day Program                                                           o Half Day Program

Please Indicate the date you wish your child to start:_____________________________________________

o $50.00 Registration Fee Enclosed (Registration Fee is Non-Refundable and not part of the Tuition Fees)

                                             óThank you for making our family a part of your family. ó