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Childs Name

Address

Apt. #

AgeDate of Birth

Zip

Home Phone #

Mothers Name

Fathers Name

Occupation Work #

Occupation Work #

Emergency Name & Telephone #

Starting Date

Please check the following:

I understand that I am registering my child for t he school year and will losemy deposit if I withdraw for any r eason other than losing my employment

or moving from the area.

Parents signature

OFFICE USE ONLY Date _______________

Receipt # __________________

Membership _______________

Liability ___________________

Accident __________________

Security Deposit ___________

STARTING SEPTEMBER 10, 2012

An After School Day Care Programfor children of Working Parentsin Kindergarten to Sixth Grades

(co-ed)

School Grade/Class

Tues.Mon. Wed. Thurs. Fri.

Early Wednesday/First Friday 6:00 - 6:30 p.m. coverage

Fathers Cell

Mothers Cell

2012-2013 Registration Form

2012 - 2013School Year

S c h o ol B a s e d S i t e s

W e al s o of f er A f t er S c h o ol C ar e ,

K i n d er g ar t en 6 t h Gr a d e

a t t h ef ol l owi n g s c h o ol s :

P S 7 ( E s c or t s er vi c eP S 2 0 7 a n d P S 3 7 )

P S 1 6 9 B a y c h e s t er S c h ol a r s

B r onx C omm uni t y C h a r t er S c h o ol

C A L L R u t h M o or e ,P r o gr am S e c r e t ar y : ( 7 1 8 ) 9 4 4 - 3 2 0 7

F or A l l P r o gr am s , 8 : 0 0 am 3 : 3 0 pm

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