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2017 - 2018 APPLICATION FORM


             TODAY’S DATE_______________________________


            CHILD'S NAME________________________________________________________________________________________________  
                                                            (FIRST)                               (MIDDLE)                                (LAST)


           HOME ADDRESS_______________________________________________________________________________________________   
                                                           (NO. & STREET)                           (TOWN)                       (STATE/ZIP)


           HOME TELEPHONE _________________________BIRTH DATE_________________ AGE AT ADMISSION _______


          FATHER'S NAME ______________________________ MOTHER'S NAME ____________________________________


          FATHER’S CELL #_____________________________ MOTHER’S CELL#____________________________________


         BUSINESS ADDRESS __________________________  BUSINESS ADDRESS ________________________________


        BUSINESS TELEPHONE #_______________________ BUSINESS TELEPHONE #_____________________________


       HOURS AT WORK _____________________________ HOURS AT WORK ________________________________    


       ALLERGIES/SPECIAL DIET _________________________________________________________________________


      INDIVIDUAL HEALTH PLAN FOR A CHILD WITH A CHRONIC HEALTH CONDITION? _______ IF YES, PLEASE ATTACH.


      ANY CUSTODY AGREEMENTS, COURT ORDERS AND RESTRAINING ORDERS.______ IF YES, PLEASE ATTACH COPIES.

      LIMITATIONS OR CONCERNS._______________________________________________________________________


     PLACE OF BIRTH­­ _________________OTHER MEMBERS OF HOUSEHOLD ________________________________


     SEX ______ HGT. ______ WGT. _____ HAIR COLOR ________EYE COLOR__________


     E-MAIL ADDRESS ___________________________________________ PRIMARY LANGUAGE __________________


     NATIONAL ORIGIN _________________ IDENTIFYING MARKS ____________________________________________


     CHILD'S PEDIATRICIAN _______________________________________ TELEPHONE #________________________


     DAYS ATTENDING (CHECK ALL THAT APPLY):

     MONDAY _______     TUESDAY_________    WEDNESDAY_______ THURSDAY ________    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. ONE MONTHLY TUITION PAYMENT FOR NEWLY              ENROLLED CHILDREN IS DUE WITH THIS FORM.  A SECOND MONTHLY TUITION PAYMENT IS DUE APRIL 1, 2017.          NOTE: These two payments are non-refundable.  The first tuition payment for children returning for a second        or third year is due MAY 1, 2017. The second payment is due JUNE 1, 2017. These two payments are non-                  refundable.


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


   PLEASE SIGN & DATE____________________________________________________________    /________________