Parent Name
Address Line 1
Address Line 2
City
State	-- Select --- Connecticut New Jersey New York Pennsylvania	Zip
Email Address
Work Phone
Child's Name
Child's Birthdate

This section is optional; if you just want more information, use the Comments
Preferred Start Date:
Jan	Feb	Mar	Apr	May	Jun
Jul	Aug	Sep	Oct	Nov	Dec

Child Care Program Choice:
Full Day: 7:30 am - 5:30 pm
Partial Day: 6 Hours or Less(PS/PK Only)
Half Day: 9 - 1 (PS/PK Only)

Days Needed:
Mon-Fri	Mon	Tues	Wed	Thurs	Fri

Montessori Program Choice :
5 Full Days: 8:45 am - 3:00 pm
3 Full/2 Half Days: 8:45-3:00 M/T/W 8:45-11:15 TH/F
Half Days: 8:45-11:15pm

How did you hear about our school? (Please check all that apply.)
Newspaper	Magazine
Yellow Pages	Friend/Co-worker
Brochure	Other
If other, please specify. (You can also use this area for comments.)