Please provide the following information about the child:

First name
Last name
Middle name
Name Usually Called
Date of Birth	Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2001 2002 2003 2004 2005 2006 2007
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Home Phone

Please provide the following information about the mother:

Name
Employer
Employer's Street address
Address (cont.)
City
State/Province
Zip/Postal code
Work Phone
Home Phone
E-mail

Please provide the following information about the father:

Name
Employer
Employer's Street address
Address (cont.)
City
State/Province
Zip/Postal code
Work Phone
Home Phone
E-mail

Please list siblings and ages in your family in the space provided below.

Choose one of the following schedules:

Full Time, (3-5 days) 7:00 A.M. to 6:00 P.M.
Part Time, (2 days) 7:00 A.M. to 6:00 P.M.
Flex Time 7:00 A.M. to 6:00 P.M.

How many days per week? 1 2 3 4 5

Select the specific days below:

Monday Tuesday Wednesday Thursday Friday

Enter the starting date : -- mm/dd/yy

Please write a short description of your child.
Include group experiences s/he might have had, and what expectations you have regarding
your child's school experience.