Registration Form

Classes:

School Year 12/13 (Runs approximately last week in August through mid-May)

3-4 year-old Tuesday / Thursday 9:15 - 11:45 a.m. (Class is Full)

3-4 year-old Wednesday / Friday 9:15 - 11:45 a.m.

4-5 year-old Tues. / Wed. / Thurs. 9:15 - 11:45 a.m.

4-5 year-old Tues. / Wed. / Thurs. 1:00 - 3:30 p.m.

Child's Name:

Date of Birth:

Boy

Girl

Parent/Guardian Name(s): (include last name if different from child's)

Home Phone:

Mother's Work Phone:

Cell Phone:

Father's Work Phone:

Cell Phone:

Mailing Address:

City:

State:

Zip:

E-mail address:

Does child have any allergies (foods, medicines, animals)
or have special needs? Please specify:

Name of Home Church:

How did you hear
about this program?

Enter the code you see
in the image here
(use correct case of letters):