application for admission

4 Newman Avenue, Rumford, RI 02916
Application is hereby made for my child to BROWN PLAY SCHOOL for the year beginning in September, 20___.
Age Group: 3 years
4 years
3-day program
4-day program
5-day program only
5-day program
Child’s Name ____________________________________________________________ Boy
Date of Birth _________________________________
Parent’s Name _______________________________________________________________________
Parent’s Name _______________________________________________________________________
Home Address ______________________________________________ email________________________
Telephone (Home) ______________________________ (Work) ________________________________
How did you hear of Brown Play School? _____________________________________________________
Parent/Guardian Signature ______________________________________________________________
Mail to: Brown Play School
4 Newman Avenue
Rumford, RI 02916
A non-refundable application fee of $40.00 must accompany this
completed form.
Do Not Fill In The Following:
Group _____________________________
Pre-Admission Immunization Form _____________________
Date Received _______________________
Authorization for Emergencies ________________________
Application Fee ______________________
P.P.D. Form _____________________________________
Date Tuition Deposit Due________________
Child Information Form _____________________________
Tuition Deposit Received ________________
Pre-Admission Physical Form _________________________
Date Acceptance Sent __________________