Teddy Bear Corner, Inc.

Address, Town, Zip Code*:

Home Phone:

D.O.B.*:

Mother:

Father:

Mother's Employer:

Mother's Cell Phone:

Father's Employer:

Father's Cell Phone:

Enrollment Desired (FULL DAYS ONLY - check only days desired):
MondayTuesdayWednesdayThursdayFriday

Approx. start date:

Would you be interested in an earlier enrollment if a spot should open? YesNo

At the time of registration, I agree to pay the non-refundable registration fee and first two weeks of tuition (if paying bi-weekly,) or the first month's tuition (if paying monthly,) plus a security fee. I understand that the security may not be applied to the last term of enrollment at Teddy Bear Corner. Should I withdraw my child prior to enrollment, I understand that I will forfeit the registration fee. Should I withdraw my child after enrollment without giving thirty (30) days written notice, I understand that I will forfeit all monies paid. (Security funds will be returned within 10 business days, minus any unpaid fees or penalties after your child's last day of the program.)

Parent Name*:

Parent Email*:

Date*: