Parent & Child Enrollment Winter 2014

• Please mark the appropriate day you would like to attend based on your child’s age group:

• April 1through June 6 No class 4/21, 5/18, 5/19, 5/20, 5/26
  • 2-6 months: Wednesday 11:30am – 12:45pm ($150)
  • 7-11 months: Monday 11:45am – 1:15pm ($120)
  • 12-18 months: Thursday 12:00am – 2:00am ($350)
  • 19-24 months: Tuesday OR Thursday 9:30am - 11:30am ($270)
  • 24-36 months: Monday OR Friday 9:30am - 11:30 ($180 or $270)
  • 18m - 4 yr: Friday 9:30am - 11:30am ($300)
• Child's Name:*
  First Last
• Birthday:*
  MM slash DD slash YYYY
• Gender:*
  • Boy
  • Girl

• Parent Name:*
  First Last
• Email:*
• Address
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Home Phone:*
• Cell Phone:

Δ

Parent & Me Enrollment Winter 2014