Parent / Guardian Information *

First Name

Last Name

Phone *

(###)

###

####

Preferred Date Start Date *

MM

DD

YYYY

Child's Information

First Name

Last Name

Birthdate

MM

DD

YYYY

Program Preferences

Summer Session

School Year Session

Year Round

Days of Care Needed

Monday

Tuesday

Wednesday

Thursday

Friday

Does your child have any special needs, allergies, or dietary restrictions?

Yes

No

Name

First Name

Last Name

Date

MM

DD

YYYY