Child's Name:

Child's Name

Date of birth (D.O.B.):

Parent 1 Name:

Last Name

First Name

Parent 2 Name:

Last Name

First Name

Phone Numbers:

Home

Cell Phone

E-mail address:

Schedule:

Half-Day 9:00am - 12:30pmFull-Day 9:00am - 3:00pm

Register for the following weeks:

June 12June 17June 24July 1July 8July 15July 22July 29August 5

Payment by:

Creadit CardCashCheck

Billing Address:

City

State

Zip Code

Parent/Guardian’s Signature:

Date :