Roseville/St. Anthony
612-455-8955
Blaine
763-784-1451
Before & After School Care
Summer Camp
Blaine Campus
St Anthony Campus
About Us
Registration
Contact
Location:
St Anthony
Blaine
Today's Date:
Starting Date:
Child Information
First Name
*
:
Last Name
*
:
Sex
*
:
Male
Female
Birth Date (or due date)
*
:
Days of attendance:
M
T
W
TH
F
Will your child have a sibling enrolled:
Y
N
Name(s):
(Please use a sepatate enrollment form for each additional child)
Elementary School:
Grade Entering in the Fall of 2010:
Parent/guardian information
Parent/Guardian Name(s)
*
:
Address
*
:
City / State / Zip
*
:
Home Phone
*
:
Work Phone:
Cell Phone:
Email
*
:
Registration fee
A non-refundable registration fee must accompany this form. The registration fee is $50 per family
How did you hear about JJs Jam:
Name of referring family:
Important Note
ENROLLMENT: Prior to your childs attendance at Jack and Jill Childcare, all enrollment information and
a parent contract must be completed, signed and returned to the office.
Signature of Parent / Guardian:
Date:
Enter Words:
not case sensitive
