Address__________________________________________________________________________________________________

Street (Apt. #) City Zip

Father's Name_____________________________________________ Occupation _____________________________

Business Address__________________________________________ Business Phone_________________________

Mother's Name____________________________________________ Occupation_______________________________

Business Address__________________________________________ Business Phone__________________________

Names & ages of brothers & sisters__________________________________________________________________

Other Family members (or live-in housekeeper) at home_______________________________________

Please list other languages with which child is familiar__________________________________________

Preferred attendance schedule: Morning / Afternoon / Full Day--- M T W Th F

Child will arrive at school at__________a.m./p.m. & leave at __________a.m./p.m.

Does your child nap?__________ Previous group experience? __________ If yes,

where & at what age?___________________________________________________________________________________

Other significant information about your child (medical/developmental, etc.):

___________________________________________________________________________________________________________

Tuition is paid the first school day of each month. Tuition schedule enclosed.

Tuition deposit due upon confirmation of enrollment. Amount Paid $_________

Referred by __________________________________________________________________________________

____________________________________________________________________ ____________________________

Parent(s)' signature(s) Date

Home Phone:_____________________________ Emergency Phone:______________________________________

(Other than Parent) Phone Name

Cell Phone (or Pager) _________________