Date of Enrollment________________ APPLICATION FOR ADMISSION Child’s full name____________________________________________________________________________ first middle last Address___________________________________________________________________________________ street city state zip Phone #__________________________________Birth date:________________________ Mother’s name ______________________________Email Address___________________________________ Mother’s occupation______________________Phone#__________________Cell#______________________ Business address___________________________________________________________________________ street city state zip Father’s name _______________________________Email Address__________________________________ Father’s occupation_______________________Phone#__________________Cell#_____________________ Business address___________________________________________________________________________ street city state zip Child’s Physician_______________________________________________Phone#_______________________ If Parents cannot be reached in an emergency, please call: (provide 2 contact names) Name___________________________Relationship__________________Phone#________________________ Name___________________________Relationship__________________Phone#________________________ In the event of an emergency, I authorize The Canaan Ridge School to allow the transport of my child by emergency vehicle to Stamford Hospital for immediate medical attention. (My child’s physician will be notified.)_________________________________________ Signature ************************** Please check the program requested for your child: Full Time Programs: Kindergarten_____1st Grade_____2nd Grade_____3rd Grade_____4th Grade_____ 3 & 5 Day Programs: Pre-K 3 Day: ______Pre-K 5 Day ______Nursery 3 Day______ Nursery 5 Day______ Monday □ AM Please check AM or PM on the days requested: □ PM Tuesday □ AM □ PM Wednesday Thursday □ AM □ PM Friday □ AM □ PM □ AM □ PM I hereby wish to make a formal application to enroll my child in The Canaan Ridge School. Enclosed is my check for $300 as a registration deposit to be credited against the full tuition payment. (I understand that this registration fee is non refundable). Parent Signature_____________________________________________Date__________________________