Return this form and $40 fee ($30 registration fee & $10 supply fee) payable to Croton Church of Christ.  
Monthly tuition is $85.

Child Name __________________________________________________________      M / F

Address  _______________________________________________________________________
           
   (Street)                                                                                                City/Zip

Age  ________        Birthday  ______________________       Class preference        _____  3 year old
                                                                                                                              _____  Pre-K
 
Phone Number  ___________________           Church Affiliation   ___________________________

Mother's Name   __________________________________________________________________

Mother's Address   ________________________________________________________________
          
                           (Street)                                                                                                City/Zip

Father's Name    __________________________________________________________________

Father's Address  _________________________________________________________________
           
                           (Street)                                                                                                City/Zip



The $40 fees are non-refundable.



___________________________________________                ________________
        
      Parent's signature                                                                                                  Date


                                           Please fill in Child information on the back.
                                                                         (BACK)

If your child prefers a nick name, what is it?  _____________________________

Does your child have any comfort items?  _______________________________

What are your child's favorite things to do?  ______________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Does your child have difficulties with any of the following?  (please write yes or no)

_____  walking        _____  talking        _____  eating        _____  toileting        _____  separation

If you answered "yes" above, please explain:

_________________________________________________________________________________________

_________________________________________________________________________________________

What are your child's favorite snacks?  __________________________________________________________

_________________________________________________________________________________________

What are your child's food dislikes?  ____________________________________________________________

_________________________________________________________________________________________

Is there any medical information or allergies?  _____________________________________________________

_________________________________________________________________________________________

Is there any other information you would like us to know about your child?  ______________________________

_________________________________________________________________________________________
SEE BELOW