If you would like to receive admissions information, please provide us with the following:

Parent's Name

First Name
Last Name
Street Address
Address (cont.)
City
State
Zip Code
Work Phone
Home Phone
E-mail

Child's Name

First Name
Last Name
Birth Date	-- mm/dd/yy
Sex	Male Female

Type of program you are interested in:

Day Care Kindergarten Summer Day Camp

If Day Care:

2 day 3 day full time

If part time, specify days:

Monday
Tuesday
Wednesday
Thursday
Friday

Has your child ever been in Day Care before?

Yes No

Date you are looking to start :

-- mm/dd/yy

How did you hear about our program?

Additional Comments: