Application / Registration Form 2018/2019 School Year

The Cottage School Program You Wish to Register For

Please Check All That Apply

Mommy/Daddy and Me Fall Program

Mommy/Daddy and Me Spring Program

Playgroup: 2 days (9-11am)

Preschool: 5 days / 3 days / 2 days (9 am to 12:30 pm)

Young K / Kindergarten (9 am to 1:30 pm)

1st - 2nd - 3rd - 4th - 5th - 6th - 7th - 8th Grades: (8:30 to 2:30 pm)

Foreign Language Enrichment: Spanish / Russian

Physical Education Enrichment: Zumba / Yoga

Spanish/Art Summer Program

Foreign Language Enrichment Program

Please select one

Physical Education Enrichment Program

Please select one

Your Email

Child's Name *

Child's Name

First Name

Last Name

Date of Birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address if Different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

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Parent #1 Name

First Name

Last Name

Parent #1 Cell Phone Number

(###)

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Parent #1 Work Place and Address

Parent #2 Name

First Name

Last Name

Parent #2 Cell Phone Number

(###)

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Parent #2 Work Place and Address

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

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Pediatrician Name and Contact Info

Dentist Name and Contact Info

Allergies or Medical Problems

Other Important Information