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

Preferred Start Date:
Jan	Feb	Mar	Apr	May	Jun
Jul	Aug	Sep	Oct	Nov	Dec

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

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.)