Parent Registration Form

Date: _________________________

Name of parent(s)

____________________________________________________

Address ____________________________________________________

Phone # home______________ work ________________

cell ___________________ Email_____________________________________________

Name of child #1 _____________________________ Birth date _________________

Name of child #2 _____________________________ Birth date _________________

Name of child #3 _____________________________ Birth date _________________

Desired start date ____________________________

Special needs/interests of child_____________________________________________

License Number: ________________________________________________________

Start Date: _______________________________________________

Language:

 Bilingual – English & Spanish

 Spanish