Chai Tots Preschool

Child's Name *
Date of Birth*
Child's Home Address*

Parent or Guardian Information

Mother's Name*
Address *
Mother's Cell *
Mother's E-mail *
Occupation and Place of Employment
Phone Number
Father's Name *
Address *
Father's Cell *
Father's E-mail*
Occupation and Place of Employment


I am interested in*
I need Early/Aftercare Care (Additional $15 per hour, per child)
Days of the week you prefer (if applicable)
Please note that there are no guarantees for day preferences. We will do our best to accommodate you.
Does your child have any allergies?
Are there any medical problems that we should be aware of?
I reviewed the guidelines and regulations and I hereby register my child for the Chai Tots Day Camp Summer of 2021. Registration fee and Day Camp Tuition are non refundable.
Signature of Parent*