Registration Form

Child's Information

Are you registering more than 1 child?

yes

Name *

Date of Birth

Month *

Day *

Year *

Name of 2nd Child

2nd Child Month

2nd Child Day

2nd Child Year

Name of 3rd Child

3rd Child Month

3rd Child Day

3rd Child Year

Name of 4th Child

4th Child Month

4th Child Day

4th Child Year

Previous School Experiences

Home Address

Street 1 *

Street 2

City *

State *

Zip Code *

Home Phone *

Parents' Information

Parent/Guardian 1

Name

Cell Phone

Occupation

Employer

Work Phone

Guardian 1 Email *

Parent/Guardian 2

Name

Cell Phone

Occupation

Employer

Work Phone

Guardian 2 Email

Physician/Emergency Contact:

Physician

Family Physician

Phone

Emergency Contact

Phone

In addition to the guardians listed above, who else is authorized to pick up your child?

1 - Name:

1 - Cell Phone

2 - Name:

2 - Cell Phone

3 - Name:

3 - Cell Phone

4 - Name:

4 - Cell Phone

5 - Name:

5 - Cell Phone

Code Word for pickup:

Other Children in Family:

More Than 2?

Yes

Name

Age

#2 Name

#2 Age

#3 Name

#3 Age

#4 Name

#4 Age

#5 Name

#5 Age

Are you registering your child for:

School Year

Yes

$150

Summer Camp

Yes

$100

Child's School Calendar

Peppermint Tree

Toms River School

Choose Summer Camp

Jr. Camp

School Age Camp

Current Grade

Sessions:

Mini Camp

Session 1

Session 2

Session 3

Weekly Schedule

Monday

Monday From:

To:

# of Hours

Tuesday

Tuesday From:

To:

# of Hours

Wednesday

Wednesday From:

To:

# of Hours

Thursday

Thursday From:

To:

# of Hours

Friday

Friday From:

To:

# of Hours

Desired Start Date

How did you hear about The Peppermint Tree?

Choose One

Explain

Peppermint Tree

Child's Information

Home Address

Parents' Information

Parent/Guardian 1

Parent/Guardian 2

Physician/Emergency Contact:

Physician

Emergency Contact

In addition to the guardians listed above, who else is authorized to pick up your child?

Other Children in Family:

Are you registering your child for:

Weekly Schedule

Monday

Tuesday

Wednesday

Thursday

Friday

How did you hear about The Peppermint Tree?

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