2-Year Old Program Interest Form

Date

Month

Day

Year

Registration Fee: $100 - I understand that this fee is non-refundable and will be paid after school tour.

Acknowledge

Print Name as Signature

Child's First Name

Child's Middle Name

Child's Last Name

Gender

Address

Child's Date of Birth

Month

Day

Year

Home Phone

Parent's First Name

Parent's Last Name

Employer

Occupation

Work Phone

Cell Phone

Siblings(Name and Age)

Church Affliliation

Doctor's Name

Doctor's Phone #

Doctor's Address

Emergency Contacts

If your parent can't be reached

Name

Phone

Relationship

Name

Phone

Relationship

Please select program time preferred: (A $40.00 administrative fee will be applied for a program change)

8:15am - 10:15am

9:15am - 11:15am

10:30am - 12:30pm