Registration of Interest in Placement at Shady Lane School
I am interested in enrolling my child in the Shady Lane School five-day program. I understand that I must pay $25 to register this intent. I understand the fee is waived if I qualify for subsidized childcare funding.
Child's Name
*
First Name
Last Name
Child's Birth Date
*
-
Month
-
Day
Year
Date
Child's Sex
*
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Parent/Guardian #1
Name
*
First Name
Last Name
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
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Parent/Guardian #2
Name
First Name
Last Name
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
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Enrollment Details
Desired Placement For Your Child
*
Infant (6 weeks - 12 months)
Young Toddler (Must be 1 by September 1)
Toddler (Must be 2 by September 1)
Preschool (Must be 3 by September 1)
Desired Time
*
Full Day (8:00 - 3:00) (Pre-School Only; 3 by September 1)
Extended Day (8:00 - 6:00) (Infants, Toddlers, Preschool)
Enrollment Preference
*
As soon as space is available
Request specific date
Does your child receive subsidized childcare funding (such as CCW or ACCM)?
*
Yes
No
Are you interested in applying for tuition scholarships?
*
Yes
No
Does your child receive any outside supports (such as speech theraphy, physical therapy, etc.)?
*
Yes
No
If you answered yes, what services?
Has your child been enrolled in school before?
*
Yes
No
If you answered yes, where?
If you answered yes, what was the reason for leaving?
Name of any siblings or parents (if any) who are attending or have attended Shady Lane School:
How did you hear about Shady Lane School?
Friend
Shady Lane Website
Social Media
NAEYC Website
Other
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Payment
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( X )
Fee
$
25.00
Pay with PayPal
Please click one of the PayPal options to complete payment and
submit
the form.
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