Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

June Extension Pickup Contact

First Name

Last Name

Pick Up Contact Phone

(###)

###

####

Does Child Receive Special Services *

No

Speech

OT

PT

Other

Program (please select) *

June School Extension runs May 28th until June 21st. You may select any 1 -4 weeks ($150/$200/$250wk) below:

Week 1: May 28th- May 31st ($200)

Week 2: June 3rd - June 7th ($250)

Week 3: June 10th - June 14th ($250)

Week 4: June 18th, 20th, 21st ($150-3days)

Child 2 Name

First Name

Last Name

Child 2 Date of Birth

MM

DD

YYYY

Does Child 2 Receive Special Services

No

Speech

OT

PT

Other

Program (please select)

June School Extension runs May 28th to June 21st. Select any 1 -4 weeks ($150/$200/$250wk). Please select from the below:

Week 1: May 28th - May 31st ($200)

Week 2: June 3rd - June 7th ($250)

Week 3: June 10th - June 14th ($250)

Week 4: June 18th, 20th, 21st ($150-3 days)