After School Tutoring Program  2007 - 2008

                                                 Enrollment Application
Application Date:  Date of Availability:
                                                        
                                                   Child’s Information
Child’s Name:
Birth date: Birth Place:

                                     Mother’s/ Guardian’s Information
Mother/Guardian’s full name:
Birth date:  Birth Place:
Home Address:
City: State: Zip Code:
Home Phone: Mobile Phone:
E-mail address:
Occupation:
Work Address:
City: State: Zip Code:
Work Phone: ext.

                                       Father’s/ Guardian’s Information
Father/Guardian’s full name:
Birth date:  Birth Place:
Home Address:
City: State: Zip Code:
Home Phone: Mobile Phone:
E-mail address:
Occupation/Profession:
Work Address:
City: State: Zip Code:
Work Phone: ext.


                             Please check one of the following in each box
       Application Category

Walk-in   HFDC Participant   Sibling,Sibling’s Name   CentroNía Mary Center Floc,   CentroNía’s Staff,Staff´s Name: Name of FSW   Referral, Name of Agency Name of person making the referral Payment Category (Please check one)    Full Tuition                             Subsidy Information of the School where you child is enrolled during the school year Name of School: Address: Current Grade: Room Number/Name Signature:   Date: FOR OFFICE USE ONLY Date application Received Initial Security Deposit Paid   Yes Amount of $ No Waived   Cash   Chek No   Money Order Initial Enrollment Date: Group’s Name