Desired Class: _____________________

Childs Name: ________________________________ Date of Birth:______________

Gender (circle): Male Female

Street Address: ______________________________ Home Phone: ______________

City/State/Zip: ______________________________

Parent/Guardian Name: Parent/Guardian Name:

______________________________ ______________________________

Address (if different from child): Address (if different from child):

______________________________ ______________________________

______________________________ ______________________________

Home Phone: ___________________ Home Phone:___________________

Work Phone: ___________________ Work Phone: ___________________

Cell Phone: ___________________ Cell Phone: ___________________

Valid E-Mail Address: Valid E-Mail Address:

______________________________ ______________________________

Please initial each of the following:

_____I understand the $75 registration fee is non-refundable and holds my child’s place in his/her designated class and covers necessary start up expenses.

_____I understand that this class is cooperative, and I will participate as many as 2 days per month.

_____I understand this school is cooperative and requires 10 hours per year of participation on a school committee.

_____I understand that fundraising is an integral part of the schools operation and each family participates in fundraising efforts. I also understand that each family may be responsible for $100 in fundraising efforts for the school year.

_____I understand the information on this application is used for classroom communication and will be published on a class list.

_____I understand that it is customary for students names and/or photographs to be used in classroom projects, newsletters, web-site, and other school communication and I will notify the school office in writing if I do not wish for my child’s’ name or image to be used.

Parent Signature:_____________________________________Date:_______________