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Child's Name:________________ Date of Birth: __________________

Street Address: ____________________________________________

City/Town: ________________State:_________ Zip Code:__________

Home Phone: ___________________

Parent/Guardian:_________________ Parent/Guardian: ___________

Occupation:_____________________ Occupation: ________________

Business Address:_________________ Business Address: _________

Work Telephone:__________________Work Telephone: ____________

Home Address (if different):                     Home Address (if different):
__________________________           ___________________________
__________________________           ___________________________

Desired Start Date: ___________
Desired Schedule:
                      M            T             W             TH            F
From/To:
         ________________________________________________
(no drop off after 9:15am, pick up times are 12:30pm or after 2:45pm)

Child's Pediatrician/Clinic: _________________ Telephone: ____________

Parent Signature: ________________________Date: _________________

Please complete and return this form with $40 non-refundable application fee