At Little Acorns Preschool

Registration for “2018 Summer Adventures” Program

at Little Acorns Preschool

Child’s Name:(Last)______(First)______M____ F______

Date of Birth: ______Nickname:______

Age as of August 31, 2018 ______Does your child speak English? Yes____ No____

Child lives with: Mother/Father/Both/Other (Please circle) Primary Email:______

Address:______City & Zip:______

Parent Name:______Parent Name:______

Parent Cell #1:______Parent Cell#2:______

House Phone:______

If your child has any special needs, please explain:______

______

Current/Prior School: ______

Please select the weeks and times your child will attend:

(pick between Option 1 or 2 each week)

Option 1 Option2 (children bring a lunch from home)

______Week 1 May 29th-June 1st (9-12 T-F) ______Week 1 May 29th-June1st (9-1pm T-Th; 9-12 Fri)

(Fairy Tale Fun) $80.00 $85.00

______Week 2 June 4th- 8th (9-12 M-F) ______Week 2 June 4th- 8th (9-1pm M-Th; 9-12 Fri)

(A Bug’s Life) $100.00 $105.00

______Week 3 June11th-15th (9-12 M-F) ______Week 3 June 11th-15th (9-1pm M-Th; 9-12 Fri)

(Outer Space Adventures) $100.00 $105.00

______Week 4 June 18th-22nd (9-12 M-F) ______Week 4 June 18th-22nd (9-1pm M-Th; 9-12 Fri)

(Kids in the Kitchen) $100.00 $105.00

_____ Week 5 June 25th-June 29th (9-12 M-F) ______Week 5 June 25th-June 29th (9-1pm M-Th; 9-12 Fri)

(Rumble in the Jungle) $100.00 $105.00

**Note that week 1 of camp is a 4 day week due to Memorial Day, hence the adjusted fee.

Payment Schedule:

Payment for your child’s first week of camp due with this registration form. The fee in NON-REFUNDABLE

·  Balance for remaining weeks due by May31st

Mother:

Occupation:______Name of Workplace:______

Phone Number of Workplace:______

Father:

Occupation:______Name of Workplace:______

Phone Number of Workplace:______

If the parents are divorced or separated, what is the custody arrangement for the child?

Is there a language other than English spoken in the home and to what extent?

What else would you like the staff to know about your child? (add separate sheet if needed)

______

Parent Signature and Date

First Week Payment Received on ______Check Number ______