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Infant (6wks-18Mos) Registration Form
for 2008-2009 School Year.

Please submit one form per child.

* Required fields are marked with an asterisk.

This child is:* a current child in the program.
a sibling of a current child in the program.
a new child to the program.
Child's Birthday*
(Birthday after March 1, 2007)
Gender* Boy
Girl
Unknown
Information About Your Child
Child's Name*
First:
Middle:
(optional)
Last
Name to be used at school
Child's Address*
City, State, zip*
Parent/Guardian Information
Parent/Guardian Name*
Relationship to Child*
Parent/Guardian Occupation
Parent/Guardian E-mail*
Parent/Guardian Home Address
If different from Child's Address.
Parent/Guardian City, State, Zip
Parent/Guardian Home Phone
Parent/Guardian Cell Phone
For Emergency Contact
Place of Business
Business Phone
For Emergency Contact
Additional Parent/Guardian Information
Parent/Guardian Name
Relationship to Child
Occupation
E-mail
Home Address
If different from Child's Address
City, State, Zip
Home Phone
Cell Phone
For Emergency Contact
Place of Business
Business Phone
For Emergency Contact
Additional Information
Names & Ages of Siblings
Have any of your other children attended Dimensions First-Plymouth Early Education Programs before? Yes
No
Special Information
Information that would be helpful for Teachers to know.
Financial Information
Optional
Sponsor a Child		 I (We) would like to contribute an extra $10 each month to help a child who needs financial assistance. (This is a tax-deductible contribution). Thank You.
Assistance I (We) need financial assistance and have completed the information below.
Total Gross Income per Month
Income other than Salary
Comments
Circumstances which may affect financial needs.

Amount I am able to pay each month
This information will be held in the strictest confidence. Assistance will be determined based upon need and number of qualified applicants. You will be notified if tuition assistance is available.
Session Information

Choice of Sessions
Please register for your ideal schedule, but mark here if you are flexible with days (and/or) times.

 I am flexible with days.
I am flexible with times.
I am flexible with days and times.

Early Morning Session
Designed to use before the infant sessions. (Available from 7:45 - 9:00 AM)

Enter drop off time
between 7:45-9:00 AM
Mon:
Tue:
Wed:
Thu:
Fri:
Infant Sessions*

Morning - M/W/F.............9:00 to 11:30 AM
Morning - T/Th.................9:00 to 11:30 AM
Morning - M thru F...........9:00 to 11:30 AM

Full Day - M/W/F.............9:00 AM to 3:00 PM
Full Day - T/Th.................9:00 AM to 3:00 PM
Full Day - M thru F...........9:00 AM to 3:00 PM

Late Afternoon Session
Designed to extend the Full-Time infant sessions (Available until 5:15 PM)
Enter pick-up time
between 3:00-5:15 PM
Mon:
Tue:
Wed:
Thu:
Fri:

Note: Fields marked by an asterisk (*) are required.
2045 E Street, Lincoln, NE 68510   402-476-8304   fax: 402-476-8060   info@dimensionsfoundation.org