Registration Form- SUMMER

Registration Form- SUMMER
Summer Early Childhood Education Program

for 3-5 years old
Child's Name

First NameLast Name
Birthday

MonthDayYear
Date
Allergies
Mom's Name

First NameLast 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 NameLast 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

CityState / 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 1 - June 1 & 3 (June 2 & 4 is full)
Week 2 - June 8-11
Week 3 - June 15-18
Week 4 - June 22-25
Week 5 - June 29-July 2
Week 6 - July 6-9
Week 7 - July 13-16
Week 8 - July 20-23
I agree to pay Week 1-4 by June 1, 2026
I agree to pay Week 5-8 by July 1, 2026
Payment Type
Should be Empty:

Summer Early Childhood Education Program