Registration Form- SUMMER
Summer Early Childhood Education Program
for 3-5 years old
Child's Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Allergies
*
Mom's Name
*
First Name
Last Name
Mom's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mom's Email Address
*
example@example.com
Dad's Name
First Name
Last Name
Dad's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dad's email address
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Pick Up Person (other than Mom and Dad)
First Name
Last Name
Area Code
Phone Number
Schedule
Please check all that apply. Choose 2 days or all 4 days per week.
Week 6 - July 6-9
Monday
Tuesday
Wednesday
Thursday
Week 7 - July 13-16
Monday
Tuesday
Wednesday
Thursday
Week 8 - July 20-23
Monday
Tuesday
Wednesday
Thursday
I agree to pay Week 1-4 by June 1, 2026
*
Agreed
I agree to pay Week 5-8 by July 1, 2026
*
Agreed
Payment Type
*
Cash/Check
ACH, additional 1% fee
Credit Card, additional 2.99% fee
Submit
Should be Empty: