Please print, fill out, sign and return form to us at New Life Christian Early Learning Center

2795 Patterson Drive, Aliquippa, PA 15001.

NEW LIFE CHRISTIAN EARLY LEARNING CENTER

2795 Patterson Drive, Aliquippa, PA 15001 Phone 724-378-6066

Registration: $25.00 Fee Must Accompany This Form

Child’s name:_____________________________________Birth Date:___________

Address:_____________________________City_____________Zip Code:________

Parent’s Names:________________________________________________________

Phone:_________________________________________________________________

Employer(s) name and Phone:_________________________________________________________________

Name and Phone of person to be contacted in case of emergency:____________________________________________________________

Hospital Child is to be taken to in emergency:___________________________

Child’s Physician:_______________________________________________________

Health Insurance Co.:______________________Insurance #_________________

Special disabilities of child:______________________________________________

Special medical or dietary information:__________________________________

Date child was toilet trained:____________________________________________

Transportation will be supplied by:_______________________________________

Person to whom child may be released- specify all persons other than parents:________________________________________________________________

School district in which you reside:_______________________________________

It is my understanding that medical care, if required will be paid by me. I also give permission for New Life Christian Early Learning Center to provide transportation to field trips via parent volunteers. It is also my understanding that I am responsible for providing refreshments approximately one day per month (playgroup) or approximately once every six weeks (pre-kindergarten) as assigned. I understand that tuition is based on a yearly fee that is payable in monthly installments. I agree to pay the first day school is in session for the month and no later than the 5th of each month. I agree to the policies of the school as outlined in the policy manual.

SIGNATURE OF PARENT OR GUARDIAN_________________________________

Class preference upon availability (circle):

Pre-Kindergarten AM Pre-Kindergarten PM

Playgroup AM Playgroup PM

Date:

Student Information

Child’s name:_____________________________________

Birth Date:______________________ Sex M/F (please circle)

Age on September 1 ^st _______________

Child’s home address:________________________________________

Child’s home phone number:_________________________________

Parent or Guardian Information

Father’s name: ______________________________________________

Address: ____________________________________________________

Phone: _____________________Cell phone: _____________________

Employer(s) name and Phone: _______________________________

Mother’s name: _____________________________________________

Address: ___________________________________________________

Phone: ____________________ Cell phone: _____________________

Employer(s) name and Phone: _______________________________

Family Information :

Brothers and/or sisters and their ages: _________________________

_____________________________________________________________

Emergency information

Name and number of person to be contacted in emergency: _____________________________________________________________

Health Insurance: ____________________________________________

Special disabilities of child: ___________________________________

_____________________________________________________________Special medical or dietary information: _______________________

Date child was toilet trained: ________________________________

Child’s previous School/ Daycare experience:_________________

_____________________________________________________________

Transportation will be supplied by:_____________________________

Person to whom child may be released- specify all persons other than parents: __________________________________________

_____________________________________________________________

School district in which you reside: ____________________________ Have you had a child previously attend at New Life? __________