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ilding <br />~OCk NURSERY SCFIOOL AND DAY CARE CENTER <br />Summer .Registration Form <br />Name of Child <br />Street <br />Last <br />First Middle <br />City Zip <br />Father's Name Address <br />Mother's Name Address <br />Age <br />Phone <br />Child's Physician Phone <br />(Your child should have a physical examination before classes begin this summer) <br />STATE PREFERENCES FOR ATTENDANCE: <br />Weeks <br />First Session: June 4-29 <br />Second Session: July 2-27 <br />Third Session: July 30 -Aug 24 <br />Check as many sessions and times as <br />you would like your child to attend. <br />Times <br />9:00 - 11:00 am ~ 1:00 - 3:00 pm <br />9:00 - 11:00 am ~ 1:00 - 3:00 pm [] <br />9:00 - 11:00 am Q 1:00 - 3:00 pm <br />CHECK ONE: <br />2 days -Tuesday, Thursday $25.00 complete (4 week program) <br />Q 3 days -Monday, Wed. ,Friday $35. 00 complete (4 week program) <br />0 5 days -Monday thru Friday $45.00 complete (4 week program) <br />If you wish to schedule a day and time other than the above, please indicate here: <br />TO COMPLETE REGISTRATION: This form and the $5.00 registration fee* may be mailed <br />in or dropped off at any of the centers listed above. <br />*Medical insurance program is <br />covered through registration fee. <br />