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CHILD'S NAME
BIRTHDATE  MALE FEMALE
HOME ADDRESS
CITY STATE
ZIP TELEPHONE
CONTACT NAME
HOME ADDRESS
HOME TELEPHONE
WORK TELEPHONE
CELL PHONE
How did you hear about RCN?
Check program(s) you are interested in:
Toddler Preschool Special Education
Program
K-Wrap Before & After School:
Before School Only After School Only
Before & After School:
Before School Only After School Only
Summer Camp (K- 5th) Universal Pre-Kindergarten Program
If "Toddler" is selected, how many days are you requesting?
If "Preschool" is selected, how many days are you requesting?
SCHEDULE
Hours Requested Starting Date Requested
Do you anticipate you will be receiving funding through DSS?
(or) Do you anticipate paying full tuition privately?
Briefly describe your child, the kind of program you are looking for and any specific questions you may have:
Your E-Mail Address:
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