WEE Registration Form 2010/2011

REGISTRATION APPLICATION

Severna Park Baptist Church-Weekday Early Education Center

506 Benfield Road, Severna Park, Maryland 21146

410-647-8162

OFFICE USE ONLY -CLASS: ________________________________________________

Date of Application __________________________________________________________

Child's Name_______________________________________________________________

(last) (first) (middle) (name used)

Sex_____ Date of Birth______/______/______ Place of birth_______________________

(Must be 2 - 3 - 4 by SEPTEMBER 1st)

Address__________________________________________________________________

(street) (city) (state) (zip)

Phone__________________________ Email_____________________________________

Names and ages of siblings____________________________________________________

___________________________________________________________________________________

Father'sName______________________________________ Cell# __________________

Occupation_____________________________ Business Number____________________

Mother's Name_____________________________________ Cell # __________________

Occupation_____________________________ Business Number____________________

Church Affiliation __________________________________________________________

How did you find out about our program? ________________________________________

Phone number to call in case of emergency when home cannot be reached:

Name______________________________________ Phone________________________

(Page 1)

May teacher call doctors if necessary? _____yes _____no

Physician________________________________________ Phone____________________________

Dentist__________________________________________ Phone____________________________

Remarks____________________________________________________________________________

___________________________________________________________________________________

I understand that the first tuition payment is due on or before July 1st. With this payment as

commitment to attend the school, my child's place in the assigned class is secured.

I further understand that this payment is NON-REFUNDABLE and all decisions concerning

my child's readiness should be made prior to payment.

NOTE: POTTY TRAINING IS NECESSARY FOR 3'S AND 4'S.

REGISTRATION FEE: $85.00 (NON-REFUNDABLE AND DUE AT TIME OF REGISTRATION)

Payable to: SPBC WEE CENTER

SIGNATURE:_____________________________________________________________

Please circle the class of your choice:

MEDICAL FORMS RECEIVED: _____YES _____NO

DATE____________________________ INITIALS_____________

(Page 2)

Print out form and mail or deliver to Judy Myer at 506 Benfield Road, Severna Park, MD 21146