Rosen JCC: Early Childhood School Registration and Membership Application

Dear parents,

It's that time of the year again! Please complete this form to begin the Early Childhood registration process for the 2017-18 School Year. Once you have completed this form, we will be in touch with you to collect final paperwork. Please note that registration is on a space-available basis, and that space is not guaranteed until you receive a confirmation within 5 business days.

The registration process is not complete and no child can start until all paperwork has been received by the JCC. This includes emergency information, immunization, health documentation, and financial arrangements.

You must fill out ONE APPLICATION PER CHILD. If you have more than one child, please submit this application and then re-start a new one for each additional child.

Questions? Contact Dr. Phyllis Bochman at PhyllisB@rosenjcc.org or 407-319-4702.

Child's Name *

First Name Last Name

Current Classroom *

Gender *

Male Female

Cutoff Date

- Month - Day Year

Birthdate *

- Month - Day Year

Age as of 8/31/17

This is calculated automatically based on the birthdate above.

Allergies/Special Needs *

If none, please enter "None" in the box.

Home Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone *

- Area Code Phone Number

Parent 1 Name *

First Name Last Name

Parent 1 Birthdate *

Date

Relation to Child *

Parent 1 Cell Phone *

- Area Code Phone Number

Parent 1 E-mail *

If there are two parents, do they live together? *

Yes No Only 1 parent

Parent 2 Name

First Name Last Name

Parent 2 Birthdate *

Date

Relation to Child

Parent 2 Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Parent 2 Cell Phone

- Area Code Phone Number

Parent 2 E-mail

What is the relationship between the two parents?

Married/Partners Divorced/Separated Widowed

Program *

Infants (Full-Day) - 2 months year by 8/31/17 Mobile Infants - 8 months by 8/31/17 Toddler A - 12 months by 8/31/17 Toddler B - 18 months by 8/31/17 Twos - 2 years by 8/31/17 Threes - 3 years by 8/31/17 Pre-K/VPK - 4 years by 8/31/17

Intended Start Date

- Month - Day Year

How many months will your child be attending? *

10 months (August-May) 12 months (August-July)

Program Hours (Toddlers & Twos)

5 days (Mon-Fri), 9am-12:30pm 5 days (Mon-Fri), 9am-3pm 5 days (Mon-Fri), 7am-6:30pm 3 days (M/W/F), 9am-3pm 3 days (M/W/F), 7am-6:30pm 2 days (Tu/Th), 9am-3pm 2 days (Tu/Th), 7am-6:30pm

Program Hours (Threes)

5 days (Mon-Fri), 9am-3pm 5 days (Mon-Fri), 7am-6:30pm 3 days (M/W/F), 9am-3pm 3 days (M/W/F), 7am-6:30pm

Program Hours (Pre-K)

5 days (Mon-Fri), 9am-3pm 5 days (Mon-Fri), 7am-6:30pm 5 days (Mon-Fri), 9am-12pm (VPK only)

Do you want your child to nap?

Yes No

Do you need extended care from 8-9 a.m.?

Yes ($100/month) No

Please read and check each item. *

Registration Fee *

Returning Families - $200 New Families - $250

Employee Code

If given an Employee Code, enter it here. Otherwise, leave this blank.

By signing below, I agree that I have read and understand the terms of ECLC enrollment, the Membership Agreement and the Waiver, Release and Indemnification Agreement. *

Today's Date

- Month - Day Year

Additional Comments