CONTINUED CARE REGISTRATION

2009-10 SCHOOL YEAR

Parents Name____________________________________________________________

Address_________________________________________________________________

City_________________________________________Zip________________________

Home Phone_____________________________________________________________

Mother’s work___________________________________________________________

Mother’s Cell phone_______________________________________________________

Father’s work____________________________________________________________

Father’s Cell phone_______________________________________________________

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

__________________________________________________                    ___________

__________________________________________________                    ___________

__________________________________________________                    ___________

PLEASE CIRLCE THE SERVICE YOU NEED:

Morning Care:        5 Days      3 Days     2 Days   Afternoon Care:    5 Days     3 Days     2 Days  

Please list  below any person(s) and their phone numbers you wish to authorize to pick up your child(ren).  You MUST list at least one person in case of an emergency!

__________________________________________________        _________________ 

_________________________________________________          _________________ 

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

Paid by check #_________________   Date of Payment:  _______________