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 ________________
