Registration Child's Name* First Last Start Section 1Name Child goes byEnd Section 1Start Section 2Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Section 2Start Section 3Sex*MaleFemaleEnd Section 3Parent/Guardian's Names*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Subdivision Section BreakStart Section 4PhoneEnd Section 4Start Section 5PhoneEnd Section 5Start Section 6PhoneEnd Section 6Section BreakStart Section 7Primary Email End Section 7Start Section 8Secondary Email End Section 8Section BreakStart Section 9Physician's NameEnd Section 9Start Section 10Physician's Phone NumberEnd Section 10Does your child have allergies?Does your child receive any special services?Any special comments about your child that you feel would be helpful to the teachers?(Please include any known fears, medical conditions, etc.)Section BreakStart Section 10Are you a Member of Leesburg Presbyterian Church*YesNoEnd Section 10Start Section 10How did you hear about our preschool?End Section 10Tuition Costs: For the 2021/2022 school year you have two options when it comes to our enrichment program. 1. You can sign up by semester. We offer 2 semesters...Semester #1 goes from September-January and encompasses our first 4 themes. Semester #2 goes from February-May and covers our last 4 themes. Just fill out the online registration form (choosing am or pm) and once received we will contact you to find out which semester you are interested in. This is the most economical way to sign up because the cost for each session in that semester is $160. 2. Need more flexibility this school year? Then signing up per session will be better for you. Pick the theme(s) you like best, decide if you want an am or pm class, and then fill out the online registration form. Once your registration is submitted you will be contacted to find out what month/theme you are registering for. The cost for this option is $170 per session that you sign up for. Age Class Days Single Session Tuition Full Semester Enrollment 3 by 09/30/2021 Morning, 2-Day Tu, Th 9:30 - 12:00 $170 p/s $160 p/s 4 by 09/30/2021 Morning, 2-Day Tu, Th 9:30 - 12:00 $170 p/s $160 p/s 3 by 09/30/2021 Afternoon, 2-Day Tu, Th 12:30 - 2:30 $170 p/s $160 p/s 4 by 09/30/2021 Afternoon, 2-Day Tu, Th 12:30 - 2:30 $170 p/s $160 p/s Time Together - Wednesdays, 9:30 - 10:45 am, $120 p/sClass Selection*Please select which class you are enrolling forMorning EnrichmentAfternoon EnrichmentTime TogetherNameThis field is for validation purposes and should be left unchanged.