Enrollment Form 


Weekday Early Education Program 

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Child's Name Birthdate Sex 

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Parents' Relationship to Each Other: Q Married Q Divorced Q Separated Q Single 

(If divorced, a copy of the Divorce Decree noting guardianship, days of visitation, etc. must accompany this 
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Child lives with (please check all that apply): 
Q Mother and Father Q Mother Q Father Q Other 

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Father's Name ' Driver's License 
Home Address Phone 
City State Zip. 
Occupation Employer 
Work Phone Pager Mobile 

Mother's Name Driver's License 
Home Address " Phone 
City State '-•.'. Zip. 
Occupation ; Employer 

Work Phone Pager Mobile. 

Family religious preference Church membership •. . ' 

How did you find out about our program? 

List at least one local person who will be available to assume responsibility for your child in an emergency if 
parents cannot be reached. 

Name Relationship to child 
Address Driver's License 
City State * Zip. 
Occupation Employer 
Work Phone Home Phone Mobile Phone