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FUMP Registration 2021-2022
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Name of child:
Your answer
Birth Date: ___/___/____
MM
/
DD
/
YYYY
Sex: M __ F___
Male
Female
Clear selection
Address:
Your answer
City, State, Zip Code:
Your answer
Child lives with: ___both parents ____Only Mother ____Only Father _____Other (Explain)
Your answer
Full Name of Mother/Guardian:____________________________
Your answer
Mothers Address if different from Childs:
Your answer
Home Phone:
Your answer
Cell Phone:
Your answer
Email:
Your answer
Work Phone:
Your answer
Place of Work:
Your answer
Full Name of Father/Gaurdian:
Your answer
Father's address if different from child:
Your answer
Home Phone
Your answer
Cell Phone:
Your answer
Email:
Your answer
Work Phone:
Your answer
Place of Work:
Your answer
Person's to contact in case of Emergency/authorized to pick up Child:
Your answer
Name of Childs Doctor:
Your answer
I authorize that the above person(s) may be contacted in case of emergency: (By checking this box acknowledges my signature for the above question.)
Option 1
Signature of Parent/Gaurdian: (Please Type)
Your answer
I Would like to Enroll my child in the following class:
2-3 Year Old Class - Monday/ Wednesday/Friday 8:00 to 11:15 am Child must be 2 years of age on or before August 31, 2021. The cost is $175 per month
2-3 Year Old Class - Tuesday/Thursday, 8:00 to 11:15 am Child must be 2 years of age on or begore August 21, 2021. The cost is $140 per month.
3-4 Year Old Class - Monday/ Wednesday/Friday 8:00 to 11:15am. Child must be 3 years of age on or before August 31, 2021 and must be completely potty trained. Cost is 165.00 per month
3-4 Year Old Class - Tuesday/Thursday 8:00- 11:15 am. Child must be 3 years of age by August 31, 2021 and must be completely potty trained. Cost is $125 per month.
4-5 Year Old Class - Monday/Wednesday/Friday 8:00 am - 11:30am. Child must be 4 years of age by August 31,2021 and must be completely potty trained. The cost is $165.00 per month
4-5 Year Old Class - Tuesday/Thursday 8:00 am - 11:30 am. Child must be 4 years of age by August 31,2021 and completely potty trained. The cost is $125 per month.
4-5 Year Old Class - Everyday 8:00 - 11:30 am. Child must be 4 years of age by August 31,2021 and must be completely potty trained. The cost is $220.00 per month.
Other:
I agree to pay FUMP $100 Registration Fee. These can be dropped off at the Preschool office or mailed to PO Box 696, Pilot Mountain NC, 27041
I agree
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