ADMISSIONS APPLICATION
Entrance Date*
Required field!
Withdrawl Date
Required field!
PARENT'S SS#
Required field!
Child's First Name
Required field!
Child's Last Name
Required field!
Child's Date of Birth
Required field!
Mothers Name
Required field!
Mothers Phone Number
Required field!
Mothers Address
Required field!
City
Required field!
State
Required field!
Zip
Required field!
Name
Required field!
Mothers Work Phone
Required field!
Father's Name
Required field!
Work Name
Required field!
Name
Required field!
City
Required field!
State
Required field!
Name
Required field!
Name
Required field!
Who Does Child Live With?
Required field!
Childcare will be provided Monday thru Saturday, but cannot exceed five days"
Our hours are from 5:30 "4..M. until 2:0t MÐNIGHT. After t hours" there is
a late fee of $10"00 every 15 minutes after" Childcare fees are payable every
Monday" Registration fee is $50"00
