Text Box: Corkran United Methodist Preschool and Kindergarten 5200 Temple Hill Road Temple Hills, MD 20748 (301) 894-6886 www.corkranschool.org Two Year Old Registration Form for 2012 - 2013 (Children MUST be Two Years Old by September 1st) A non-refundable Registration Fee of $125.00 must accompany this form. Name of Child________________________________________________________________ Sex (M/F) __________ Last First Middle Home Address____________________________________________________________________________________ Street City State Zip Code Date of Birth_____________ Email Address __________________________________ Home Phone ___________________ Father’s Name___________________________________ Work Phone__________________________________ Father’s Place of Work_____________________________ Cell Phone____________________________________ Mother’s Name___________________________________ Work Phone___________________________________ Mother’s Place of Work____________________________ Cell Phone____________________________________ Names & Ages of Siblings_____________________________________________________________________________ Indicate Any Allergies or Health Problems________________________________________________________________ Child’s Doctor____________________________________________ Doctor’s Phone_____________________________ Emergency Contact________________________________________ Phone____________________________________ (OTHER THAN PARENTS) NAME RELATIONSHIP Supply Fee: $125.00 (one time fee) Please circle your class preference. Tue. /Thurs. (2 day group) Mon/Wed/Fri (3 day group) Mon.-Fri. (5 day group) 9:00 – 11:30 a.m. 9:00 – 11:30 a.m. 9:00 – 11:30 a.m. Tuition: $230.00 per month Tuition: $280.00 per month Tuition: $ 395.00 per month I hereby give permission for my child _________________________________________ to participate in school trips, walks, etc. during the school year. I understand that I will be notified of all plans in advance. If I do not choose for my child to participate, I will keep my child home that day. Photo release (initial your choice): My child’s photo MAY BE used in the hallway or the web site ___________ OR My child’s photo may NOT be used in the hallway or the web site___________ I agree to pay the monthly tuition and any extra care costs that my child has accrued while enrolled in Corkran Preschool. Notification of withdraw must be given to the Office in WRITING THIRTY DAYS in advance. Parent Signature: ________________________________________________________________________________ rev.1/12

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