Name Parent/Guardian 1 *

First Name

Last Name

Cell Phone: Parent/Guardian 1 *

(###)

###

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Work Phone: Parent/Guardian 1 *

(###)

###

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Name: Parent/Guardian 2

First Name

Last Name

Cell Phone: Parent/Guardian 2

(###)

###

####

Work Phone: Parent/Guardian 2

(###)

###

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Child's Name *

First Name

Last Name

Child's Gender

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Child's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone

(###)

###

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Does Child Receive Special Services *

No

Speech

OT

PT

Other

Program (please select) *

School Year Programs Run September - May begining at 9am - 11:45am. Please select how many days your child will attend. Schedules are subject to adjustment to maintain daily ratio of 5:1. Early enrollment is given priority.

3 days: $5,055

4 days: $5,450

5 days: $6,290

Enrichment Program

Child 2 Name

First Name

Last Name

Child 2's Gender

Male

Female

Child 2 Date of Birth

MM

DD

YYYY

Child 2 Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child 2 Home Phone

(###)

###

####

Does Child 2 Receive Special Services

No

Speech

OT

PT

Other

Program (please select)

School Year Programs Run September - May begining at 9am - 11:45am. Please select how many days your child will attend:

3 days: $4,815

4 days: $5,190

5 days: $5,990

Enrichment Program