Child's Name: ___________________________________Nickname:______________________ D.O.B.: _____/_____/_____

Address:______________________________________________________ Home Phone:___________________________

Father's Name: _______________________Employer:_______________________ Phone:___________________________

Mother's Name:_______________________Employer:_______________________ Phone:___________________________

Guardian, if other than parent:___________________________________________ Phone:___________________________

Work or Emergency Telephone: __________________________________________________________________________

Doctor's Name & Telephone: ___________________________________________ Phone:___________________________

Other Children in Family & Ages:__________________________________________________________________________

Religion: ____________________________________________________________________________________________

Other School Experiences: ______________________________________________________________________________

Anything else that may contribute to a better understanding of your child:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

PLEASE CHECK YOUR PREFERENCE:

My child may participate in school-sponsored field trips: ___________________________(please sign)

A $30.00 non-refundable registration fee (all applicants) and first month's tuition (new applicants only) must accompany application in order for application to be processed.  I have received a copy of the school policies and thoroughly understand them and will abide by them.

Signed:___________________________Print Name:_________________________ Date of Application: _____/_____/_____

 

Please feel free to call 453.9846 for an appointment

or if you have any questions about Kiddie Kollege.