Palos Heights CRC

Parent First Name:

Parent Last Name:

Email Address:

Address:

City:

State:

Zip Code:

Phone Number:

Student First Name:

Student Last Name:

Student's Birth Date:

Sessions:
Two days/week(9:00-11:30am) Three days/week(9:00-11:30am) Four days/week(9:00-11:30am) Five days/week(9:00-11:30am) Two days/week(9:00-11:30am) with early drop off and/or extended class time Three days/week(9:00-11:30am)with early drop off and/or extended class time Four days/week(9:00-11:30am)with early drop off and/or extended class time Five days/week(9:00-11:30am)with early drop off and/or extended class time Two days/week(12:15 pm- 2:45pm)

Please indicate which days you would like your child to attend and which days for early drop off and/or extended class time if applicable along with any Comments/Questions: