REGISTRATION APPLICATION
(Please print or
type.)
Birth Date: _____ /______/____
Child’s Name:
____________________________________________________ Nick
Name:_____________
(Last)
(First)
(MI)
Address:__________________________________________ Town:
____________________ Zip:________
Home Phone No. (____) ______-_________ Cell
Phone:(_____) _____-__________ E-Mail:____________
Father’s Name: _______________________________ Mother’s
Name:_____________________________
Sister’s, Brother’s &
Ages:_________________________________________________________________
Father’s 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
______________________________________________________________________________________
Nursery
Days 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
Kindergarten
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)
—Thank you for making our family a part of your family. —
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