Marina Children's Center Application for Enrollment |
3219A Laguna Street, San Francisco, CA 94123 - (415) 931-0833 http://www.marinachildren.com |
Child's Name: _________________________ | Nick Name: ___________________________ | |
Male: ____ Female: _______ | Date of Birth: _________________________ | |
Home Address: ________________________ | City: ________________________________ | |
____________________________________ | Zip: _________________________________ | |
Mother's Name: _______________________ | Father's Name: ________________________ | |
Home Phone: _________________________ | Home Phone: _________________________ | |
Work Phone: _________________________ | Work Phone: _________________________ | |
Cell Phone or Pager: ___________________ | Cell Phone or Pager: ___________________ | |
Email: _______________________________ | Email: _______________________________ | |
Program Preference | ||
Approximate Days Needed: | Extended Care: | |
______ Tuesday & Thursday ______ Monday, Wednesday, and Friday ______ Five Days |
______ 4:00 - 6:00 |
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Notes:
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Our $50.00 Application Fee is Non-Refundable Your child will be place on our waiting list. See http://www.marinachildren/choices.htm for Enrollment Steps. |