Madison Public Schools TO ESTABLISH RESIDENCY STUDENT ENROLLMENT

Madison Integrated PreschoolMadison Town Campus Learning Center (TCLC)2014-2015 Typical PeerFees and Program SelectionSTUDENT / PARENT INFORMATIONLast Name: First Name: Middle:Date of Birth: Gender: Male FemaleParent/Guardian:Address:Telephone Numbers:Home Phone: Cell Phone: Work Phone:Emergency Contact (other than parent)Phone NumberRelationship to StudentFEE AND SESSION SELECTIONFull day is available for our current tuition students, ages 3-5, and those who have been screened and determined to be typicallydeveloping. There are a limited number of spaces available on a first-come, first-serve basis.Select the 3 day, 5 day or Other program. Fee is $20 per session for 1/2 day, $30 per session for full day (minimum 3 days a week for fullday)3 day - 1/2 day program $60 per week5 day - 1/2 day program $100 per week3 day - full day program $90 per week5 day - full day program $150 per weekAM sessionPM SessionPlease select days attending:Monday Tuesday Wednesday Thursday FridayA screening for typical peers is required. Please bring this completed form and your deposit check of $100 (which will be deductedfrom your first invoice) to TCLC to register and schedule an appointment for screening.There is an AM and a PM session Please indicate your preference. We will make every effort to honor your preference. If we are fullyenrolled in AM or PM and cannot honor your preference, we will call you to check on your interest in the available session. If the AM/PMsessions are filled, a waiting list will be maintained.PaymentMadison Public Schools will send you a monthly invoice. The invoice will indicate the number of school days, due date, and paymentamounts.Please make all checks payable to Madison Public Schools (please do not include cash).