RCDN Enrollment Application
Student Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Gender
Please Select
Male
Female
N/A
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Program you are applying for
Please Select
PreK 3
PreK 4
Allergies - if your child has any allergies, please list them below:
Guardian Information
Guardian #1 Name
Guardian #2 Name
Guardian #1 E-mail
Guardian #2 E-mail
Guardian #1 Mobile
Guardian #2 Mobile
Guardian #1 Occupation
Guardian #2 Occupation
Will you be requesting exempt status? ***Exempt status is for families who are unable to assist in the classroom and will pay a higher tuition rate. Exempt status will be granted to a limited number of families after Executive Board review.***
Yes
No
Emergency Contacts
Please provide two emergency contacts OTHER THAN THE CHILD'S PARENTS. In the event of an emergency, those individuals listed below will only be contact if we are unable to reach the child's parents.
Emergency Contact #1 Name
Emergency Contact #2 Name
Emergency Contact #1 Phone
Emergency Contact #2 Phone
Emergency Contact #1 Location
City, State
Emergency Contact #2 Location
City, State
Emergency Contact #1 Relation to Child
Emergency Contact #2 Relation to Child
Additional Comments
The undersigned agrees to participate as a parent helper (unless granted exempt status), serve on at least one committee, attend all General Meetings and pay a non-refundable Application Fee of $125.
*
Date
*
-
Month
-
Day
Year
Date
Print Form
Submit Application
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