Centennial Preschool

2008-2009 Registration Form

Name ________________________________________ Birthdate ________

(First) (Middle) (Last)

Address _______________________________________________________

______________________________________________________________

Home Phone ________________ Email __________________________

Mother's Name _____________________________ Cell Phone __________

Employer _________________________________ Work Phone _________

Father's Name _____________________________ Cell Phone ___________

Employer ________________________________ Work Phone __________

IN CASE OF AN EMERGENCY, PARENTS WILL BE NOTIFIED FIRST; HOWEVER, TWO ALTERNATES ARE NEEDED IF FOR ANY REASON PARENTS CANNOT BE REACHED.

Emergency Contact _____________________________________________

Phone ___________________ Relationship to child ____________________

Emergency Contact _____________________________________________

Phone ___________________ Relationship to child ____________________

Other Children in the family:

Name ______________________________________ Age ______________

Church Home__________________________________________________

Child's Doctor ______________________________ Phone ______________

Child's Dentist ______________________________ Phone _____________

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Registration Fee: (Per Returning Family) $35.00 New Family $40

Supply Fee: (per child) $65.00

These fees are due upon registration and are nonrefundable after June 1st.

__________________________________________

(Signature of Parent of Guardian)

I am registering for: M/W/F Class_____ T/TH Class_____ MDO--Day_____

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For office use: Date of check ________ Check Number ________ Check Amount _________