Registration Form


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Registration Form

Child’s Name: ____________________________________________________ Date of Birth:_____________________

Mother’s Name:____________________________________ Father’s Name: __________________________________

Home Address: ____________________________________________________________________________________

City: _____________________________________________________ State: ________ Zip/Postal Code: ____________

Telephone: (______)__________________ Email: ________________________________________________________

When do you need care to start: ______________________________________________________________________

How did you hear about the center: ____________________________________________________________________

A non-refundable security deposit equal to one week of tuition/CCIS copay is required at the time of registration. The security deposit is applied towards your last week of tuition. The first week of tuition is due the Friday before care is scheduled to commence.

Parent’s signature: ______________________________________________________________ Date: ______________

DO NOT WRITE BELOW THIS LINE

.........................................................................................................................................................................................

Heath Assessment Enrollment Form Emergency Contact

TB Assessment CCIS Authorization Getting to know you

Last physical Parent Consent IEP

Classroom Assignment (circle one)

Toddlers Pre-School/Pre-Kindergarten AM Kindergarten Grades 1-12



Center Rep. Name:__________________________________
Center Rep. Signature:_______________________________


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