Child's Legal Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Date of Birth *

MM

DD

YYYY

Child's Gender *

Male

Female

Preschool Age (Not been in a Pre-k program) *

Full Time (weekly cost: $200)

Part Time (weekly cost: $130)

Pre-K (not yet attended Kindergarten)

Full Time (weekly cost: $180)

Part Time (weekly cost: $120)

School Age (going into 1st-4th grade)

Full Time (weekly cost: $150)

Part Time (weekly cost: $100)

Does the child have a mother? *

Yes

No

Mother's Name *

First Name

Last Name

Does the mother live with the child? *

Yes

No

Mother's Date of Birth *

MM

DD

YYYY

Mother's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Phone Number *

(###)

###

####

Is this child's mother employed? *

Yes

No

Mother's Employer's Address *

N/A if not applicable

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Work Number *

(###)

###

####

What's the best way to contact the mother? *

Cell Phone

Work Phone

Email

Does the child have a father? *

Yes

No

Father's Name *

N/A if not applicable

First Name

Last Name

Father's Date of Birth *

MM

DD

YYYY

Does the father live with the child? *

Yes

No

Father's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Phone Number *

(###)

###

####

Is the father employed? *

Yes

No

Father's Employer's Address *

N/A if not applicable

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Work Phone *

(###)

###

####

What is the best way to contact father? *

Cell Phone

Work Phone

Email

Marital Status *

Single

Married

Divorced

Legally Separated

Other

Does the child live with the person listed above? *

Yes

No

Who is financially responsible for the child's tuition? *

Custodial Mother

Custodial Father

Other

Financially Responsible Person's Name

First Name

Last Name

Financially Responsible Person's Date of Birth

MM

DD

YYYY

Financially Responsible Person's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the person responsible for tuition employed?

Yes

No

Financially Responsible's Employer's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Financially Responsible's Phone Number

(###)

###

####

Financially Responsible's Work Number

(###)

###

####

Best way to contact this person

Cell Phone

Work Phone

Email

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone *

(###)

###

####

Best way to reach emergency contact *

Cell Phone

Work Phone

Child's Physician *

First Name

Last Name

Physician's Phone Number *

(###)

###

####

Does your child have any siblings? *

Yes

No

Sibling's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Sibling's Gender

Female

Male

Sibling 2's Name

First Name

Last Name

Sibling 2's Date of Birth

MM

DD

YYYY

Sibling 2's Gender

Female

Male

Sibling 3's Name

First Name

Last Name

Sibling 3's Date of Birth

MM

DD

YYYY

Sibling 3's Gender

Female

Male

Does anyone else live in the house with the child? *

Yes

No

Person's Name

First Name

Last Name

Person's Gender

Female

Male

Person's Date of Birth

MM

DD

YYYY

Do you attend a church regularly? *

Yes

No

Would you like more information about New Haven United Methodist Church? *

Yes

No

Payment of the registration fee is nonrefundable *

I agree

Tuition is due by Friday each week. If you do not sign up for an automatic payment, a 5% increase to child's tuition will be added. *

I agree

I will keep my child home if they are showing signs of illness or communicable disease. *

I agree

I will pick up my child promptly by the end of class each day. If late, I will pay a late student pick-up fee, or adhere to guidelines of late pick-up. *

I agree