Ballestrini's

Child Care Centers

ballestrini.net

 

Registration Form

 

Child's Name: _______________________

D.O.B________________ Age: _________

 

Home Address_______________________

City _______________Zip Code_________

Home Tel. Number____________________

 

Mother's Name_______________________

Address____________________________

City _______________Zip Code_________

Home Telephone Number_______________

Employer _____________Tel. #_________

Address____________________________

 

Father's Name_______________________

Address____________________________

City _______________Zip Code_________

Home Telephone Number_______________

Employer _____________Tel. #_________

Address____________________________

 

Start Date: ______________

 

Schedule (please circle days and list hours below)

Monday Tuesday Wednesday Thursday Friday

 

 

 

___________________________________

 

 

 

 

______________________ _________

Parent Signature Date

 

Please fill out and send this form in

with the $35.00 registration fee.