REGISTRATION FORM

LITTLE LIGHT OF MINE CHILD CENTER

Please return this completed form to Little Light of Mine Child Center. A nonrefundable Registration Fee of $50.00 will be charged WHEN YOUR CHILD IS ACCEPTED INTO LLOM. All services are $4.00/hour.

Today's date:

Child's Name:

First Name

Last Name

Sex:

Male

Female

Child's Birthdate:

Parent's Names

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Email

Identified Special Needs?

Yes

No

Identified Special Needs Description (Provide copy of IEP)

Identified Allergies:

PRESCHOOL

Please check the age appropriate class. Classes to be determined.

KINDERGARTEN

Half Day Kindergarten (Birthdates on/before 12/1/2020)

A ONE-TIME CURRICULUM FEE WILL BE CHARGED IN ADDITION TO THE HOURLY $4.00/HOUR RATE.

AS STAFFING PERMITS

WRAPAROUND CARE - 7:30 A.M.-5:30 P.M.

NAPS:

Yes

No

Days & Hours Needed:

ADDITIONAL INFORMATION:

REGISTRATION FORMLITTLE LIGHT OF MINE CHILD CENTER

PRESCHOOL

KINDERGARTEN

AS STAFFING PERMITS

REGISTRATION FORM

LITTLE LIGHT OF MINE CHILD CENTER