CFMLP Registration Form


	Clara Fields Multicultural Literacy Program


	The Science Of Reading - The Art Of Teaching


	Creating prolific readers of pre-k children by the time they enter kindergarten!


	Creating prolific readers of pre-k children by the time they enter kindergarten!


	Child Registration Form Complete a Form for each Child

E-mail Address: *

Date: *

Relationship to child: *

Your First Name *

Your Last Name *

Address *

City *

State *

Zip Code *

County *

Home Phone *

Cell Phone

Name of Preschool/Daycare

Preschool/Daycare Phone

Emergency Contact *

Emergency Contact Phone *

Child First Name *

Last Name *

Age *

Date of Birth * / /

Ethnicity *

If Other, identify

State any medical or physical condition your child has that we should be aware of?

State any concerns you may have regarding your child literacy, i.e. (confuses "d" with "b")?

Child Primary Language

Does your child have a sibling attending also? *

If yes, what is their name?

Will you be attending our Regular School Year - September to May? *

Will you be attending our Summer Program - June to August? *

Do you need Tuition Assistance? *

How did you hear about us? *

* Required


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