PS-Plus Registration Form

CHILD’S NAME  ________________________________ BIRTHDATE ____/____/____

                            Last                                      First

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

CURRENT HEARTPRINTS FAMILY:            YES                 NO

SPECIAL CONSIDERATIONS:

_____________________________________________________________________ 

A nonrefundable registration fee of $25.00 must accompany this form.

Checks should be made payable to HeartPrints.

DATE RECEIVED  ___________________          STAFF  _________________________