Registration

Registration Information
Childs Full Name*
First Name Last Name
Birth Date*

Month Day Year

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent/Guardian 1*
First Name Last Name
Relationship to Child*
Phone Number*
E-mail*
Jewish Status*

JewishConvertedJewish
Parent/Guardian 2
First Name Last Name
Relationship to Child
Phone Number
E-mail
Emergency Contact*
First Name Last Name
Relationship to Child*
Phone Number*
E-mail
Jewish Status*

JewishConvertedJewish
Program Selection
For dates and rates, please visit the dates and rates page or click here.
Class*

Toddler (18-36 Months)Preschool (3-5 Years)
Days Attending*

Monday-Friday (Full Program)MondayTuesdayWednesdayThursdayFriday
Extended Care*

YesNo
Authorized Pick-Up
Please list anyone (other than parents) authorized to pick up your child.
Full Name
First Name Last Name
Relationship to Child
Full Name
First Name Last Name
Relationship to Child
Full Name
First Name Last Name
Relationship to Child
About Your Child
Is your child potty trained?*

YesNoWorking on it
Does your child have any allergies?*

YesNo
Does your child take any medications?*

YesNo
Medical concerns we should know about*
Physician*
First Name Last Name
Phone Number*
Favorite activities*
Comfort items (if any)*
Languages spoken at home*
Anything else you'd like us to know about your child?*
Permissions
I give permission for my child to:*

Be photographed for school newsletters/social mediaReceive sunscreen provided by the parentReceive emergency medical treatment if I cannot be reached
Parent Agreement
I understand that:*

Tuition is due according to payment scheduleSick children should remain at home until they are wellOnly authorized adults may pick up my childI will notify the preschool of any changes to my contact information or emergency contactsI have read and understand the preschool policies
Parent/Guardian Signature*
Date

Month Day Year
Registration Fee*

$35
Registration processing fee

$0.00
Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

I would like to receive news and updates by email
Should be Empty:

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Registration Information

Program Selection

Authorized Pick-Up

About Your Child

Permissions

Parent Agreement