Enrollment Application

The Park Slope Schoolhouse admits students of any race, color, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national or ethnic origin in administration of its educational policies, scholarship programs, and athletic and other school administered programs.

Child’s Name
Date of Birth (mm/dd/yyyy)
Sex
Address City State Zip
Apt.#
Telephone (xxx-xxx-xxxx)
Person(s)responsible for tuition payments
Parent’s Name
Place of Work
Work Phone
E-mail address
Cell Phone
Address & Home Phone (if different from above)
Parent’s Name
Place of Work
Work Phone
E-mail address
Cell Phone
Address & Home Phone (if different from above)
Schedule choice -please indicate order of preference (i.e. 1st,2nd,3rd)*: Five Days M,W,F T,Th
Card Type --Select Card Type-- Visa MasterCard American Express
Card Number
Card Holder Name
Expiration Date Month 01 - Jan 02 - Feb 03 - Mar 04 - Apr 05 - May 06 - Jun 07 - Jul 08 - Aug 09 - Sep 10 - Oct 11 - Nov 12 - Dec Year 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
CCID
	Enroll & Pay

*We will try to accommodate everyone, unfortunately space is limited, we might be able to accommodate you with your 2nd or 3rd choice. If you are only interested in one schedule please just indicate the schedule of choice, this will communicate to us that you are not interested in an alternative schedule.

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