Smoky Row Children's Center

PRIMARY INFORMATION:
Please complete this top section to include your child's primary application information. All fields are required.

Today's Date*

Your Child's Name*

Birth Month*

Birth Day*

Birth Year*

Gender*

Street Address*

City*

State*

Zip*

Phone*

Parent 1 Name*

Parent 1 Occupation

Parent 1 Phone

Parent 1 Email*

Parent 2 Name*

Parent 2 Occupation

Parent 2 Phone

Parent 2 Email*

SERVICE DESIRED
Please select the TYPE and DAY of service desired below. Select ALL days that apply.

FullDay-M

Full-Mon

FullDay-T

Full-Tue

FullDay-W

Full-Wed

FullDay-TH

Full-Thur

FullDay-F

Full-Fri

Note: Kindergarten is Monday through Friday plus before/after care 8:45am through 3:00pm.

Kindergarten

Note: Summer Camp is for children 6 to 8 years old and held from 7:00am to 6:00pm, M-F. Please select the days you would like your child to attend. Select ALL that apply.

Summer Camp-M

SC-Mon

Summer Camp-T

SC-Tues

Summer Camp-W

SC-Wed

Summer Camp-TH

SC-Thur

Summer Camp-F

SC-Fri

Start Date