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Enrollment Application FOR OFFICE USE ONLY

First Day of Attendance Teacher
Please check service desired:

Full educational preschool program - 8:00 - 2:30 M T W TH F
Extended Day Care neededYes No Occasionally
1. Full name of child
Name usually called Social Security No.
Date of Birth Birthplace
Home Address City
Telephone No. Zip
2. Parents are: Separated Widowed
3. Father's Name
Home Address
Occupation Employer
Work Address
Work Hours Work Phone
Mother's Name
Home address
Occupation Employer
Work Address Work Phone