Name    _____________________________________________________

Address    ___________________________________________________

                 ___________________________________________________

Phone        ___________________________________________________

Date of Birth    ________________________________________________

Daily Schedule:  (Check only one)
_____ A.M.  8:00-12:00
_____ A.M. & P.M.  8:00-3:00
_____ A.M., P.M. & Extended Hours  8:00-5:30

Number of Days per Week:  (Check only one)
2  _____  Circle only 2 days:  M  T  W  T  F
3  _____  Circle only 3 days:  M  T  W  T  F
4  _____  Circle only 4 days:  M  T  W  T  F
5  _____  Monday through Friday
Other _______________________________________
If your schedule will vary from week to week, please write your schedule in the space below.*

CIRCLE all the weeks you will attend:

Week 1	Week 2	Week 3
Week 4	Week 5	Week 6
Week 7	Week 8	Week 9

Please return this registration form along with $50.00 by March 15th to ensure a spot.  After March 30th I can no longer guarantee a space will be available.  All additional forms will be sent out the first week in May.

*Special Notes: