CHILD CARE APPLICATION REGISTRATION PAYMENT
Student Information:
Student Name
*
First Name
Last Name
Parent/Guardian
*
First Name
Last Name
Date of Enrollment
*
/
Month
/
Day
Year
Date
Cell Phone
*
Parent Email
*
example@example.com
*
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One Time Registration Fee
One time registration fee (non-refundable)
$27.00
$
27.00
Submit
Should be Empty: