Online-Registration

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Online Registration

Registration

Child Pre-Registration Enrollment Form

The following information is required in order to "protect and promote the health and safety" of your child. Please supply a complete response to every item on this form. If items are not applicable, please answer "N/A"

Hours of Operation: Monday to Friday 7 a.m. to 6 p.m.
Date of Enrollment:*
DD dot MM dot YYYY
Number of Children to Enroll*
Please select the number of children you are registering
Child's Information
Childs Attendance*
- Full-Time
- Part-Time
- After-School
- Summer Only
Check one
School to pick-up from*
- Madison Crossing Elementary School
- Madison Station
- Madison Avenue
- Mannsdale
Name*
Address*
Street Address City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
2nd Child's Information
Childs Attendance*
- Full-Time
- Part-Time
- After-School
- Summer Only
Check one
School to pick-up from*
- Madison Crossing Elementary School
- Madison Station
- Madison Avenue
- Mannsdale
Name*
Address*
Same Address as First Child

Street Address City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
3rd Child's Information
Childs Attendance*
- Full-Time
- Part-Time
- After-School
- Summer Only
Check one
School to pick-up from*
- Madison Crossing Elementary School
- Madison Station
- Madison Avenue
- Mannsdale
Name*
Address*
Same Address as First Child

Street Address City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
4th Child's Information
Childs Attendance*
- Full-Time
- Part-Time
- After-School
- Summer Only
Check one
School to pick-up from*
- Madison Crossing Elementary School
- Madison Station
- Madison Avenue
- Mannsdale
Name*
Address*
Same Address as First Child

Street Address City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
5th Child's Information
Childs Attendance*
- Full-Time
- Part-Time
- After-School
- Summer Only
Check one
School to pick-up from*
- Madison Crossing Elementary School
- Madison Station
- Madison Avenue
- Mannsdale
Name*
Address*
Same Address as First Child

Street Address City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Parental Information
Mother
Name*
First Last
Address*
Use Same Address as First Child

Street Address City State ZIP Code
Phone*
Cell Phone*
Email*
Employment Company Name*
Company Address*
Street Address City State ZIP Code
Employment Phone*
Father
Name*
First Last
Address*
Use Same Address as First Child

Street Address City State ZIP Code
Phone*
Email*
Cell Phone*
Employment Company Name*
Company Address*
Street Address City State ZIP Code
Employment Phone*
Payment Information
Payment of Registration Fee(s)
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Comments
This field is for validation purposes and should be left unchanged.