2006-2007 ENROLLMENT INFORMATION
Official Form Updated July 19, 2006

Child’s Name

_____________________________________________________________________ Last First Middle

Goes By____________________________ Gender M ___ F ___

Birthdate __________________ Birthplace ____________________

SS# ___________________________

______________________________________________________________________________________________
Mother’s Name Home Address Zip Hm. Phone

______________________________________________________________________________________________
Mother’s Occupation Employer Wk. Phone Cell/Pager#

______________________________________________________________________________________________
Father’s Name Home Address Zip Hm. Phone

______________________________________________________________________________________________
Father’s Occupation Employer Wk Phone Cell/Pager#

Custody (Please check one):

Joint_________Mother_________Father__________

Other:______________________________________________
Name Address

______________________________________________
Telephone Relationship

Person responsible for tuition payments:

Name:__________________________________Phone_____________________

Address if different from above:_________________________________________________

Other children living at home: Name__________________ age___________

Name__________________ age______

I AGREE TO PAY:

_________Enrollment Fee, due at time of enrollment,

_________Materials/Book Fee due by July 1^st, a late fee is applied after that date

_________Tuition per month for ten months, due no later than the 15^th of each month, August- May.

Enrollment fee is non-refundable and registration is not complete until enrollment fee is paid.

________________________________________________________________________________________
Parent or Guardian’s Signature Date

Age of child as of September 1, 2006:___________Grade completed as of August 2006:_____________

Has your child ever been in school before? ____________ Where? _____________________

Church Affiliation:

Mother_________________________________ Member? Yes________ No___________

Father__________________________________ Member? Yes________ No___________

Guardian________________________________ Member? Yes ________ No__________

Comments of any nature (difficulties, likes/dislikes, etc.) that would help the teacher help your child.

_____________________________________________________________________________________________

______________________________________________________________________________________________

AUTHORIZATION FOR FIELD TRIPS

I GIVE MY CONSENT FOR MY CHILD TO PARTICIPATE IN FIELD TRIPS OR PLANNED TRIPS AWAY FROM THE FACILITY CONDUCTED AND SUPERVISED BY THE FACILITY STAFF AND I DO GIVE PERMISSION FOR MY CHILD TO BE TRANSPORTED BY THE FACILITY FOR THIS PURPOSE.

__________________________________________________________________________________________
Parent or Guardian’s Signature Date

RELEASE OF MEDIA AUTHORIZATION

DO YOU APPROVE YOUR CHILD TO BE PHOTOGRAPHED OR VIDEOTAPED FOR:

____________School advertisements (bulletin boards, brochures, television, newspaper or internet advertising?)

____________memorabilia record of activities and events?

Name of Child:______________________________________________Age:________________________________

Parent/Guardian Signature:______________________________________Date:_______________________________