REGISTRATION FORM                                                         Date:__________________                   

Child’s Name_______________________  Date of Birth______________Allerigies__________ 

Child’s Name________________________Date of Birth______________Allergies___________ 

Child’s Name________________________ Date of Birth______________Allergies__________

Parent/Guardian Information

 Name______________________                                              Name________________________

Relationship_________________                                               Relationship___________________ 

Address_____________________                                              Address_______________________

City & Zip___________________                                                City & Zip_____________________

Home Phone_________________                                              Home Phone___________________

Cell Phone_________________ __                                            Cell Phone_____________________

Cell Phone Carrier_____________                                             Cell Phone Carrier_______________

Work Name_______________                                                    Work Name_________________

Work Phone_______________                                                  Work Phone_________________

Email address ______________________                               Email address_____________________

Requested Schedule          Full Time___  Part Time___  M___ T____W____R____F____

Requested Start Date_________________

Payments                   Private Pay__________       CCCC subsidized__________

Upon enrollment of your Child at Pleasant Park, there is a $25.00 registration fee plus a one week’s tuition, both are non-refundable.  Prior to the child’s first day at our center, the Director will schedule a time for you to meet with your child’s teachers, review policies and procedures and sign a parent contract.

Room_______________Reg. Fee____  ID Code__________ Parent Packet______