RIVERSIDE NATURE SCHOOL REGISTRATION FORM

RIVERSIDE NATURE SCHOOL an outdoor preschool program for ages 3-6

REGISTRATION FORM Student's Name: _______________________________________________________________ Date of Birth _____________________________

Sex:

M

F

Parent/Guardian Name: _________________________________________________________ Address: _____________________________________________________________________ City: _______________________________ State: ________________ Zip: _______________ Primary Contact Number: ________________ Email: ________________________________ Secondary Contact Number: _______________ Email: _______________________________

Please select all sessions that your child will be attending: ___ Mondays 9:00 - 12:30

___ Tuesdays 9:00 - 12:30

___ Wednesdays 9:00 - 12:30

Please select the applicable monthly tuition rate: ___ $120 for 1 day/week

___ $220 for 2 days/week

___ $300 for 3 days/week

I understand that I must pay first month's tuition at the time of registration in order to reserve my child's spot.

As required by the state of West Virginia, a completed Child Health Assessment containing record of immunization and a notarized Emergency Information Form must be submitted no later than August 1, 2017.

_________________________________________________

_______________________

Signature of Parent/Guardian

Date

The Riverside Project LLC | 1123 Bloomery Road, Charles Town, WV 25414 | www.theriversideproject.com/natureschool