*Child's Name
*Date of Birth	*Age (as of 9/09)
*Sex	Male Female

          *Session Preference  
               2 Day session  Morning    Afternoon
               3 Day session  Morning  Afternoon   Either
               4 Day session    Morning   Afternoon

*Parent's Name
*Street Address
*City
*State
*Zip Code
Work Phone
*Home Phone
E-mail

    Emergency Contact

*Name
*Relationship
*Home Phone

    Any talents, hobbies, or work experience you would be willing to share

         By submitting this form, you agree to the following:
            I understand that I cannot hold Lori Conover, Jamie Wilkerson, or any other persons
            responsible for any accidentally injury which may occur on the preschool premises.