Register Now for our Winter Pre-School Socialization Groups

DATES:
The Eight Week Winter Groups for 2010 begin the the week of February 15, 2010 and run until the week first week of April 2010.

LOCATION:
7200 E. Hampden Avenue #301
Denver, Colorado 80224

COST:
$1,250.00 per child, including all handouts and educational materials.

* Required Fields

*Child's Name:
Child's Date of Birth:
Mother's Name:
Father's Name:
Marital Status:	Married Divorced Separated Single
Child's Living Situation:
Mother's Employer:
*Mother's Email Address:
Mother's Telephone:	Home: Work: Cell:
Mother's Social Security Number:
Father's Employer:
Father's Email Address:
Father's Telephone:	Home: Work: Cell:
Father's Social Security Number:
Household Members & Significant Others:	Name: DOB: Relationship: Name: DOB: Relationship: Name: DOB: Relationship: Name: DOB: Relationship: Name: DOB: Relationship: Name: DOB: Relationship:
Referral Source:
Nearest relative or friend in case of an emergency:	Name: Phone:
Pediatrician:	Name: Address: Telephone:
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PAYMENT IN FULL IS DUE PRIOR TO FIRST GROUP. PAYMENTS OF $625 PER MONTH CAN BE ARRANGED WITH SECOND PAYMENT DUE BY THE END OF THE FOURTH WEEK. YOU AGREE THAT IF IT BECOMES NECESSARY TO FORWARD YOUR ACCOUNT TO OUR COLLECTION AGENCY, YOU WILL BE RESPONSIBLE FOR REASONABLE COST OF COLLECTION INCLUDING ATTORNEY FEES. NO REFUNDS WILL BE MADE FOR MISSED APPOINTMENTS.