Registration Form

Child Information

Child's Name:

Date of Birth:

Desired Enrollment Day:

Desired Schedule (Check Days):
 Monday Tuesday Wednesday Thursday Friday

Nap & Snack (Choose One):
OccasionallyEvery day my child attendsNot at this time

Morning Snacks are provided daily. Afternoon Snacks are provided when children stay for "Nap & Snack". Hot Lunch Service is available at an additional charge but must be purchased monthly.

Lunch Service (Please choose one)
I will bring my child's lunchPlease provide a hot lunch for my child.

Child's Address:

Child's City:

Child's State:

Child's Zip:

Parent Information

Name of Parent:

Parent Relation (Choose One):
MotherFatherGuardian

Home Phone:

Email Address:

Address (if different from child's):

City:

State:

Zip:

Place of Employment:

Work Phone:

Cell Phone:

Name of Parent:

Parent Relation (Choose One):
MotherFatherGuardian

Home Phone:

Email Address:

Address (if different from child's):

City:

State:

Zip:

Place of Employment:

Work Phone:

Cell Phone:

Parent Signature

Electronic Signature (Please Type Your Name):

Today's Date:

Human Verification: Please enter characters below.