Name Parent/Guardian 1 *

First Name

Last Name

Cell Phone: Parent/Guardian 1 *

(###)

###

####

Work Phone: Parent/Guardian 1

(###)

###

####

Parishioner of St.James the Less Episcopal Church? *

Yes

No

Name: Parent/Guardian 2

First Name

Last Name

Cell Phone: Parent/Guardian 2

(###)

###

####

Work Phone: Parent/Guardian 2

(###)

###

####

Additional Caregiver Name (Nanny, Pick-Up Person, etc.)

First Name

Last Name

Phone

(###)

###

####

Child's Name *

First Name

Last Name

Child's Gender *

Male

Female

Child's Date of Birth *

MM

DD

YYYY

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Home Phone *

(###)

###

####

Does Child Receive Special Services

No

Speech

OT

PT

Other

Does child have and IEP or SEIT? *

Yes

No

Program (please select) *

School Year Programs Run September - May begining at 9am - 11:45am. Please select how many days your child will attend:

5 days: $6,480

Enrichment Program

Child 2 Name

First Name

Last Name

Child 2's Gender

Male

Female

Child 2 Date of Birth

MM

DD

YYYY

Child 2 Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child 2 Home Phone

(###)

###

####

Does Child 2 Receive Special Services

No

Speech

OT

PT

Other

Does child 2 have an IEP or SEIT?

Yes

No

Program (please select)

School Year Programs Run September - May begining at 9am - 11:45am. Please select how many days your child will attend:

5 days: $6,480

Enrichment Program