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Me Too Preschool
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Me Too Preschool

2168 Diamond Hill Road                                                                     1452 Broncos Highway

Woonsocket, RI 02895                                                                        Burrillville, RI 02830

(401) 762-9339 (401) 762-5693 fax                                          (401) 567-5227 main & fax

 

Child’s Name

________________________________________________________________

                        First                             Middle                         Last

Address

____________________________________________________________________

                       Street                          City/Town                    State                Zip Code

Telephone ___________________ Date of Birth ___________________   

Male/Female

Days Child Will Attend:   M   T   W   Th   F      Time Child Will Attend ______________

Emergency Alternatives: (Must Be Reliable Contacts)

Name ______________________ Relationship ______________ Phone ____________

Name ______________________ Relationship ______________ Phone ____________

Mother’s/Guardian’s Information

Name ________________________ Address: _______________________________

Home Phone _________________ Cell Phone ____________Work Phone ___________

Employer ____________________ Employer’s Address _________________________

Job Title _____________________ Hours ________________ Days _____________

Father’s/Guardian’s Information

Name ________________________ Address: _______________________________

Home Phone _________________ Cell Phone ____________Work Phone ___________

Employer ____________________ Employer’s Address _________________________

Job Title _____________________ Hours ________________ Days _____________

Additional Children

Name/DOB __________________________ Name/DOB _______________________

Mother’s/Guardian’s Signature ____________________________________________________

Father’s/Guardian’s Signature _____________________________________________________

Today’s Date ______________________                             

Date Enrolled _____________________  CCAP # if applicable ___________________

 

For office:

DOE ________________

ASD ________________