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Peace School Registration Fall2011

Peace School Registration Fall2011

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Published by Dustin Block

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Published by: Dustin Block on Jul 25, 2011
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07/25/2011

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Original Root Zen Center

DeKoven Center
600 21st Street
Racine, WI 53403
(262) 498-5112
Peace School Registration Form
Child’s Name:
First: ______________________ Last: ________________________
Age: _____________ Date of Birth: ___________________
Parents/Legal Guardians Names:
________________________________________
________________________________________
Phone: _____________________
Emergency Phone: ____________________
Mailing Address:
Street: _________________________City: ______________
Zip: ______________
Email Address:
______________________________________________________
Alternative Contact:
(in case parent/guardian cannot be reached, contact this person)
__________________________________________
(relationship to child/family)
Alternative Phone Number: __________________________
Transportation:
(List the person/people you authorize to pick up your child from peace school.)
______________________________ ______________________________
Medical Issues/Allergies: (please list any allergies or medical issues)
____________________________________________________________
____________________________________________________________
In case of emergency please list:
Preferred Hospital: _________________________________
Family Doctor: _____________________
Phone Number: ______________________
Tuition is $60 for the frst child, and $20 for each additional child. Payment and registration
is due by September 15. Peace School accepts cash or check made out to Original Root Zen
Center. Classes will be held Thursday nights, beginning on September 22, and running weekly
through October 27, from 4:00-5:30pm. Classes will be held at the Original Root Zen Center,
600 21st St., Racine, WI.
Questions? Call Lynn Orlando at (262) 498-5112.

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