CONTINUED CARE REGISTRATION

2011-2012 SCHOOL YEAR

Parents Name   ____________________________________________

Address   ________________________________________________

City ____________________________________   Zip____________

                   (Please Number 1 through 5 in order to be called for emergency)

Home phone #_____________________________________________

Mother work #_____________________________________________          

Mother cell #______________________________________________            

Father work #______________________________________________            

Father cell # _________________________________­­­­­_____________

Mom’s email   ____________________________________________

Dad’s email     ____________________________________________

Name (s) and grades of child(ren) to be enrolled:

_____________________________________________           _______

_____________________________________________           _______

_____________________________________________           _______

_____________________________________________           _______

Please specify which Continued Care Service you need:

Morning Care:       5 days         3 days         2 days         Pay as you go

After Care:            5 days         3 days         2 days         Pay as you go

Please list below any and all people, and their phone number, who are

Authorized to pick up your child(ren).

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

 $25.00 enrollment fee must be paid at time of registration. Check #______