TODAY’S DATE_______________________________

CHILD'S NAME____________________________________________________________________________________

HOME ADDRESS__________________________________________________________________________________ (NO. & STREET) (TOWN) (STATE/ZIP CODE)

HOME TELEPHONE ____________________________

ALLERGIES__________________________________________

FATHER'S NAME ______________________________

MOTHER'S NAME ____________________________________

FATHER’S CELL #_____________________________

MOTHER’S CELL#____________________________________

FATHER'S BUSINESS ADDRESS __________________________

MOTHER'S BUSINESS ADDRESS ________________________________

FATHER'S BUSINESS TELEPHONE #_______________________

MOTHER'S BUSINESS TELEPHONE #_____________________________

(THREE) EMERGENCY PEOPLE (OTHER THAN PARENTS) IN CASE OF EMERGENCY:

1.________________________________________________________________________________________________

(NAME) (ADDRESS) (TELEPHONE)

2.________________________________________________________________________________________________

(NAME) (ADDRESS) (TELEPHONE)

3.________________________________________________________________________________________________

(NAME) (ADDRESS) (TELEPHONE)

PLACE OF BIRTH________________

OTHER MEMBERS OF HOUSEHOLD ________________________________

BIRTH DATE____________

SEX ______

HGT. ______

WGT. _____

HAIR COLOR ________

EYE COLOR__________

E-MAIL ADDRESS (OPTIONAL)___________________________________

PRIMARY LANGUAGE __________________

NATIONAL ORIGIN _________________

IDENTIFYING MARKS ____________________________________________

CHILD'S PEDIATRICIAN _______________________________________

TELEPHONE #________________________

DAYS ATTENDING (CHECK ONE):

MONDAY/WEDNESDAY/FRIDAY _______

TUESDAY/THURSDAY ________

MONDAY THRU FRIDAY ________

SESSION ATTENDING (CHECK ONE):

MORNING _________

AFTERNOON _________

FULL DAY __________

EXTENDED DAY _________

IMPORTANT: A NON-REFUNDABLE REGISTRATION FEE OF $50.00 IS REQUIRED TO RESERVE A SPACE FOR CHILD’S FIRST YEAR, $35.00 FOR A CHILD’S SECOND OR THIRD YEAR. SEPTEMBER TUITION FOR NEWLY ENROLLED CHILDREN IS DUE MARCH 1, 2010. SEPTEMBER TUITION FOR A CHILD RETURNING FOR A SECOND OR THIRD YEAR IS DUE JUNE 1, 2010. NOTE: September tuition is non-refundable.

I HAVE READ, UNDERSTAND, AND AGREE TO THE TUITION PAYMENT POLICY OF DOLLY’S NURSERY SCHOOL.

Signature____________________________________

Date_________________