Topsy Toddler Children’s Cooperative Nursery, Inc.

Application for Enrollment

Child’s Full Name______Age:______Sex:______

Last First Middle

Preferred Name for Name Tag:______Date of Birth:______

Address______

Street City State Zip

Home Phone Number:______Email Address:______

Cell Number (if desired)______Alumni?______if yes what year?______

Parents Full Name: Father______Mother______

Father’s Occupation:______Work Phone:______

Mother’s Occupation______Work Phone:______

Previous or Present

List your other children’s names and Birthdates:

1.______2.______

3.______4.______

Are there any handicaps or problems which would require special attention in school? (Be Specific) ______

Parents:

Please list any interests or hobbies you may have that would contribute to the nursery school like typing, sewing, etc…______

Are you or your spouse a Notary Public? Yes___ No____ How did you hear about Topsy?______

Would either of you be interested in substitute teaching (if needed)? Yes______No_____

Do either of you hold a current certificate of Child/Infant CPR and First Aid?

Mother: Yes____ No____ Father: Yes____ No____ if yes please list expiration date______

Please Indicate Class Preference

_____Monday/Wednesday/Friday A.M. (4 year olds)

_____Tuesday/ Thursday A.M. (3 year olds)

_____Thursday P.M. (2 year olds)

Articles of Agreement

I, the undersigned, make application to Topsy Toddler Children’s Cooperative Nursery School, an organization that is duly authorized and licensed by the Division of Child Day Care Licensing, Michigan Department of Social Services. I do this with the understanding that when my application is accepted, I will, to the best of my ability, comply with and be governed by the rules and regulations of this said organization. Further, I understand and agree on behalf of myself, my heirs, executors or administrators not to hold the members individually or collectively responsible, or any salaried or non-salaried employees or representative responsible, in the event of injury sustained or illness contracted by myself or any child or children enrolled by me, while engaged in the activities of Topsy Toddler Children’s Cooperative Nursery School, or while being transported thereto or therefrom. It is my understanding that the teacher has the authority, with the approval of the Executive Board, to terminate the participation of my child in the nursery due to an unsatisfactory adjustment within a period of five (5) weeks from the date of entry.

Signed______Date:______

Child must be 22 months of age by October 1st for the Tot Class, 3 years of age by October 1st for the 3 year old class and 4 years of age by October 1st for the 4 year old class.

PLEASE RETURN APPLICATION WITH A $45.00 REGISTRATION FEE TO KELLY RODRIGUEZ, MEMBERSHIP CHAIRPERSON. CHECKS SHOULD BE MADE PAYABLE TO TOPSY TODDLER CO-OP NURSERY.

---APPLICATION FEES NON-REFUNDABLE---