| (This application is not complete unless all blanks are filled in and the registration fee is paid) student Information Last Name_______________________________ First Name____________________________ Middle_____________________ Entering Grade_______________ Sex _________________ Date of Birth______________ SS#_______-_______-__________ Resides With: Both Parents________ Mother ______ Father ______ Other __________________ Parent / Guardian Information Mother Last Name _______________________________ First Name __________________________ DL #______________________ Address ______________________________________________________________ Phone # __________________________ City ____________________________________________________ State ______________________ Zip________________ Employer ______________________________________________ Phone _____________________ SS#__________________ Father Last Name ______________________________ First Name ____________________________ DL# ______________________ Address _______________________________________________________________ Phone # _________________________ City __________________________________________________ State ___________________ Zip _____________________ Employer __________________________________________ Phone ____________________ SS# ______-_______- ________ Guardian Last Name _____________________________ First Name ____________________________ DL# _______________________ Address _____________________________________________________________ Phone # ___________________________ City _________________________________________________ State _____________________ Zip _____________________ Employer _____________________________________________ Phone ____________________ SS# _____-_____-________ Relationship to Student ____________________________________________________________________________________ Billing Information ( Payment due by the 1st of each month ) Extended Day Care : NON REFUNDABLE ANNUAL REGISTRATION $ 400. ___________ Full Time _________ Part Time _______ MONTHLY TUITION $ 600. ___________ Send Billing statement to : Mother _______ Father ______ Guardian _________ Other / Specify ______________________ Sibling Information Name ____________________________ Entering Grade ___________ Name __________________ Entering Grade ________ I agree to pay the above amounts and will keep my account current. A $25 late fee will be assessed and accounts past 60. ____________________________________________________________________________________________________ Parent/Guardian Signature Date |
REGISTRATION 2011- 2012