Summer Application Form

Noah's Ark Preschool

Noah's Ark Preschool
2010 Summer Application

This form is to be completed for children who will attend preschool anytime during the summer of 2010. Please complete ALL of the child’s and parent’s information.

Enter data using tab to go from one field to the next.

When finished, click on the "Submit" near the bottom of this page.

Child's Information

, Child's Name      Name to be used in school
     Last Name                                   First Name
,
   Num           Street                                                                City                                                   ZipCode

Home Phone required format aaa-bbb-nnnn   Sex Male Female        Birthday required format mn/dd/yyyy
Race/Ethnic Origin
Email Address Needed to send you an acknowledgment!

Left or Right Handed Right Left Uncertain

Favorite play activities

Parent's Information
Father
,
Last Name First Name
Work Phone aaa-bbb-nnnn
Cell Phone aaa-bbb-nnnn
Email Address

Mother
,
     Last Name                                   First Name
   Work Phone   aaa-bbb-nnnn
    Cell Phone aaa-bbb-nnnn
Email Address

Emergency Medical Information

Please fill out emergency information if it is different than we have on file
Food Allergies Enter None, if appropriate
Other Allergies Enter None, if appropriate
Other Medical Info Enter None, if appropriate

Source of Medical Care


   If Not Listed - Choose Other and fill in box below

   Include Clinic's Name, Phone #, etc.

   Physician's Name

Source of Dental Care

   If Not Listed - Choose Other and fill in box below

   Include Clinic's Name, Phone #, etc.

   Dentist's Name

Choice of Hospital

   If Not Listed - Choose Other and fill in box below

    Include Hospital Name, Phone#

Persons to be called in case of emergency if unable to contact parents (may pick up child if indicated)
Name Phone aaa-bbb-nnnn Relationship
Address May Pick Up Child Yes No
Num Street City ZipCode

Name Phone aaa-bbb-nnnn Relationship
Address May Pick Up Child Yes No
Num Street City ZipCode

Other persons authorized to pick up child from preschool
Name Phone aaa-bbb-nnnn

Name Phone aaa-bbb-nnnn

Summer Tuition

9 to 12 ($14 per day)

9 to 3 ($21 per day) child will need a bag lunch from home

7:30 to 4:30 ($27 per day) child will need a bag lunch from home

Desired Class Selection

Click on ‘button’ on the days on the calendar that your child will attend preschool.

August
Monday	Tuesday	Wednesday	Thursday	Friday
^{8/16 9-12 9-3 7:30-4:30}	8/17 9-12 9-3 7:30-4:30	8/18 9-12 9-3 7:30-4:30	8/19 9-12 9-3 7:30-4:30	8/20 9-12 9-3 7:30-4:30
^{8/23 9-12 9-3 7:30-4:30}	^{8/24 9-12 9-3 7:30-4:30}	8/25 9-12 9-3 7:30-4:30	8/26 9-12 9-3 7:30-4:30	8/27 9-12 9-3 7:30-4:30

^{Tuition will be due at the beginning of each week unless other arrangements
are made in advance.}

Electronic Signature
I hereby agree to offer my signature electronically

Name
Signature
Please retype your name as proof of your signature

Make all necessary entries and then click on "Submit"

Noah’s Ark Preschool ~ 9185 Lexington Avenue North ~ Circle Pines, MN 55014 ~ 763-784-5928