BC AC

BC

AC Before and After Care Application

Child’s Information:

First Name: _________________________________ Last Name: _______________________________ Male or Female Date of Birth: ________/________/________ Child’s Address: _______________________________________________________________________

Parent’s Information:

Mother’s First Name: _________________________ Last Name: _______________________________ Cell Ph: _____________________ Work Ph: _____________________ Home Ph: ___________________ Email Address: ________________________________________________________________________ Father’s First Name: __________________________ Last Name: _______________________________ Cell Ph: _____________________ Work Ph: _____________________ Home Ph: ___________________ Email Address: ________________________________________________________________________

Emergency Contact:

Name: ______________________________ Phone: _____________________ Relationship: __________ Name: ______________________________ Phone: _____________________ Relationship: __________ In an emergency the preschool has my permission to call my child’s physician when I cannot be contacted. Dr. Name: _______________________________________ Phone: _______________________________ Which services will you need? Before Care (8 am – 9 am) _____

After Care (1 pm – 3 pm) _____

Days of the week needed for BEFORE CARE (please circle)

MON

TUE

WED

THUR

FRI

Days of the week needed for AFTER CARE (please circle)

MON

TUE

WED

THUR

FRI

Parent Signature: _________________________________ Date: ____/____/____ OFFICE USE ONLY:

Cash or Check #_________________ Amount: _________________ Registration Fee? _________ Monthly Tuition? _________ Other? _________

Date Received: _______/________/________

5912 Franconia Rd, Alexandria, VA 22310 ~ Phone: 703-971-4613. Fax: 703-971-4476 Email: [email protected]