Exceptional Early Childhood - Alexandria, Minnesota School District ...

Send Registration Form
and Fee to:
Early Childhood Family
Education, PO Box 308,
Alexandria MN 56308
Spring 2011-2012
Mail-in or drop off registrations
Recommended by February 20th, 2012
*Unless you are contacted you are enrolled in class*
Parent’s Name________________________________________ Home Phone _______________________
Work Phone _________________ Cell Phone (Mom)_________________ Cell Phone (Dad)_______________
Address __________________________________________________________________________________
E-mail Address: ___________________________________________________________________________
Class # Class Title Name of Child Gender Birthdate Fee
________1st Choice ____________________________ ______________________ M F _____/_____/_______ ________
2nd Choice Class #_______
Class Title ___________________________
________1st Choice ____________________________ ______________________ M F _____/_____/_______ ________
2nd Choice Class #_______
Class Title ___________________________
________1st Choice ____________________________ ______________________ M F _____/_____/_______ ________
2nd Choice Class #_______
Class Title ___________________________
Sibling Care Rates for Daytime Classes Only ~ Please include fee when registering.
1 Child - $10 2 Children - $20 3 Children - $30
Class# Name of Child Gender Birthdate Fee
________ _____________________________________________________________ M F _______/______/__________ ________
________ _____________________________________________________________ M F _______/______/__________ ________
Are you attending for the first time
____ Yes ____ No
Suggested Fee Scale
Please pay according to your income
for 13 weeks of class
Under - $20,000
Free
$20,000 - $35,000 $39
$35,000 - $50,000 $59
$50,000 - $75,000 $64
Above $75,000 $74
Payments may be made by check or credit card. To pay by credit
card, please provide the following:
Charge my credit card: ____Master ___Visa ___Discover
Card # _______ ______ _______ _______ Exp Date: _______
Amount $______________
Cardholder’s Signature _______________________________________
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