HeartPrints Centerfor Early Education

Regional Learning Alliance

850 Cranberry Woods Drive   Suite 1227                

Cranberry Township, PA   16066                

724.741.1008

K-Plus Registration Form

CHILD’S NAME  ________________________________ BIRTHDATE ____/____/____

GENDER:         Male  /  Female     

MOTHER’S NAME  ______________________________________________________ 

FATHER’S NAME  _______________________________________________________

GUARDIAN  ____________________________________________________________

ADDRESS  ______________________________________________________________

CITY  ______________________________________  ZIP CODE  _________________ 

PHONE NUMBER  ________________   EMAIL ADDRESS  _____________________

CLASS REQUEST:  Please indicate your preferences.  

          _____  Monday                                 1:00 – 4:00 PM

          _____  Tuesday                                  1:00 – 4:00 PM

          _____  Wednesday                           1:00 - 4:00 PM

          _____  Thursday                                 1:00 – 4:00 PM

          _____  Lunch extension                   Noon – 1:00 PM

          _____  *Special lunch extension needed

CURRENT HEARTPRINTS FAMILY:            YES                 NO

SPECIAL CONSIDERATIONS:

________________________________________________________________________

Checks should be made payable to HeartPrints.

DATE RECEIVED  ___________________          STAFF  _________________________

FEES RECEIVED  ____________________         Check #  ______________________