Application for Admission

 2013 Summer Programs

 

 

P.O. Box 283, Old Greenwich CT 06870 (203) 698-1500

Date of Application

             /               /

Child’s name

 

 

Male q  Female q

Father’s Name

 

Child’s Date of Birth

              /             /

Mother’s Name

 

Child’s Nickname

 

Address

 

 

               Street                                                                       Town                                           State            Zip

Home Telephone

(             )                                          

 

 

 

 

Mother’s cell phone

 

Father’s cell phone

 

Mother’s email

 

Father’s email

 

Care provider name

 

Care provider cell

 

 

 

 

 

 

 

 

 

Siblings:

        Name

 

Age

 

Date of Birth

 

School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am applying for my child’s admission to the following 2013 Summer program(s):

3-5

Years

q Mini-Camp June 10 – June 21 Monday through Friday             q ˝ day (9-12 or 12-3) or q Full day (9-3)

q June 24 – July 5*  q July 8 – July 19  q July 22 – Aug 2  q Aug 5 – Aug 16       Monday through Friday

*Saturday June 29 instead of Thursday July 4                            q ˝ day (9-12 or 12-3) or q Full day (9-3)

 

 

6-10

Years

q Mini-Camp June 10 – June 21 Monday through Friday            q ˝ day (9-12 or 12-3) or q Full day (9-3)

q June 24 – July 5*  q July 8 – July 19 q July 22 – Aug 2  q Aug 5 – Aug 16       Monday through Friday

*Saturday June 29 instead of Thursday July 4                            q ˝ day (9-12 or 12-3) or q Full day (9-3)

 

 

Allergies:

 

Medication:

 

Comments:

The non-refundable application fee of $50 is enclosed

 

 

Signature(s):