Application/Registration Form 2018 - 2019 School Year

3 ½ YEAR OLD (DATE OF BIRTH 10/01/14 – 03/31/15)

* denotes a required response
Today's Date *
Today's Date
Child's Name *
Child's Name
Date of Birth *
Date of Birth
Parent's Name *
Parent's Name
Address *
Address
Primary Phone # *
Primary Phone #
Please check one: *
Alternate Phone #
Alternate Phone #
Please check one:
Is your child receiving or been referred for any supplemental services? (Please Check All That Apply) *
The ONLY medication HOPE will dispense is for children with an EpiPen Jr.
CLASS CHOICES – please select choices for your child's appropriate age group:
3 ½ Year Old (Date of Birth 10/01/14 – 03/31/15)
*Child must be toilet trained by August 1, 2018
*Birth Certificate must accompany non-refundable registration fee of $150.
*Nine (9) consecutive payments begin in AUGUST and continue through APRIL. The August payment is non-refundable. The August payment may not be applied to any future month's payment.
*Sandra Rolston Fund ~ Financial need based scholarship applications are available upon request.