2008 APPLICATION

Child’s Last Name:			First:

Date of Birth:

Male   Female
Home Street 
Address:

Parent/Guardian:

Phone:

Grade Entering:

School:

E-mail:

CHILD INFORMATION

Emergency Contact:

Relationship:

Telephone #s:
Home:				Work:				Cell:
Allergies?  YES   NO 
   
If yes, please detail specific allergy and type of reaction:

Medical Conditions:  e.g. Asthma, Seizures, etc.

Has your child received Occupational Therapy Services    YES    NO

Do you have any specific areas of concern  YES  ? NO  ?

(If yes please check all that apply to your child’s needs)

Handwriting 			Sensory Integration		  Gross Motor
Visual			 	Socialization			  Coordination
Fine Motor			Other: Please explain:							

															

															

Signature of Parent/legal guardian:


Print Name:

Date:

REGISTRATION & PAYMENT FORM

Course No. N9096										# of children	 	Fee	  Total
Section OA – PK & K (ages 4-5)		July 7 – August 1	9:00am – 11:00am		_______		$225	____________
M/W or T/Th	SMART Parents Q/A 10:45-11:00am

Section OB – First & Second Grades 	July 7 – August 1	11:15am – 1:15pm		_______		$225	____________
M/W or T/Th     SMART Parents Q/A 1:00-1:15pm

Section OC – Third/Fourth/Fifth  Grades	July 7 – August 1	1:45pm – 3:45pm			_______		$225	____________
M/W or T/Th     SMART Parents Q/A 3:30- 3:45pm

Section OD – Sixth Grade: Keyboarding	July 7 – August 1	1:45pm – 3:45pm			_______		$225	____________
M/W or T/Th	SMART Parents Q/ A 3:30- 3:45pm								Insurance Fee		____$2______

         												Total 		             $ __________
Check	 MasterCard	 Discover	 Visa		Please make checks payable to: Orange County Community College

Credit Card #____________________________________________________________	Exp. Date_________________________________________

Print name which appears on credit card: ______________________________________________________________________________