1I am registering my child for the:PMO Program ______________________ $55/ month Wednesdays2-year-old class _____________________ $100/ month Mondays & Thursdays3-year-old class _____________________ $110/ month Tuesdays & Thursdays4-year-old class _____________________ $120/ month Mon, Wed & Fridays4/5 year-old Stepping Stones class ______ $150/ month Monday through FridayChild
’s Name ____________________________________________________________
(First) (Middle) (Last)Name your child prefers to be called __________________________________________
Child’s Birth date _______________________________ Child’s Age _____________
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Parent or Guardian’s Name _________________________________________________
Address ________________________________________________________________Home Phone _________________________ Work/ Cell Phone ____________________E-Mail Address __________________________________________________________
Parent or Guardian’s Name _________________________________________________
Address ________________________________________________________________Home Phone _________________________ Work/ Cell Phone ____________________E-Mail Address __________________________________________________________Siblings that live in the home (names and ages) _________________________________Emergency Contact _______________________________________________________Relationship to the child ___________________________________________________Home Phone _________________________ Work/ Cell Phone ____________________Please list any medical conditions that we should be aware of (allergies, asthma, diabetes,etc) ____________________________________________________________________Office Use OnlyRegistration Fee Paid: _______________________(Amt) Date: __________________
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