Christ Community United Methodist Church

Student *

First Name

Last Name

Sex

Male

Female

Date of Birth

MM

DD

YYYY

Age as of September 1st

3

4

5

6

Select Your Class *

3-4 Year Old Morning Program T/Th 9am to 11:30am $100 per month.

3-4 Year Old Afternoon Program T/Th 12:30pm to 3:00pm $100.00 per month.

3-4 Year Old Extended Program T/Th 9am to 3:00pm $230 per month

4-5 Year Old PreK Morning Program M/W/F 9am to 11:30am $130 per month.

4-5 Year Old PreK Afternoon Program M/W/F 12:30pm to 3:00pm $130 per month.

4-5 Year Old Pre K Extended Program M/W/F 9am - 3:00pm $305 per month.

4-5 Year Old PreK Five Day Morning Program M/T/W/Th/F 9am-11:30am $230 per month

4-5 Year Old PreK Five Day Extended Program M/T/W/Th/F 9am-3pm $535 per month

Mothers Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home

(###)

###

####

Fathers Name

First Name

Last Name

Fathers Address if different than mother

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Can we text you?

Yes

No

Which Phone(s) should we text

Mother

Father

1 . Emergency Contact

First Name

Last Name

Phone

(###)

###

####

2) Emergency Contact

First Name

Last Name

Phone

(###)

###

####

In the event of an emergency and the parents cannot be contacted, do you permit your child to be transferred to Butler Memorial Hospital

Yes

No