4 Newman Avenue, Rumford, RI 02916 APPLICATION FOR ADMISSION 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 Girl Date of Birth _________________________________ PARENT INFORMATION 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 __________________
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