Commitment to Enroll

Commitment to Enroll
Parents Name*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address*
Child's Name*

First NameLast Name
Date of Birth*
Date I would like my child to start attending:*
Full or Part Time Attendance*

Full Time (4-5 days a week)Part Time (2-3 days a week)
Tentative Weekly Schedule*
Days and times attending
Is your child completely toilet trained?*

YesNo
By filling out the above information and paying the $75.00 non-refundable registration fee I am committing that my child will begin attending the week of week starting .
Signature*

Clear
Date*

MonthDayYear
Date
Please mail the registration fee to:

St. Paul's Child Care Ministry

Attn: Maggi Easterday

3995 N 1000 W

Andrews, IN 46702

Once a registration fee has been received you will receive confermation that your child's spot has been reserved as agreed upon.
Completion of this form or any other form does not guarantee your child enrollment on requested start date. Please make sure to communicate with the director as to availability.
Should be Empty: