Pixie Registration Form

Registration

Please enter information on this form to make payment for Pixie Registration Form . The amount you need to pay is $150.00 .

Child's Name *

Child's Date of Birth *

Child's Address *

Parent's Name *

Phone *

Email *

A class list with one parent's name, phone number, and address is printed for every student at Pixie Playschool. Permission to include information on Class List? *

Yes

Typed Signiture & Date *

I understand that there is a $100(two day)/$150(four day) snack & supply fee per year that I agree to pay *

Yes

I understand that I must have a current medical statement signed by a physician for my child no later than 30 days after my child's admission *

Yes

Typed Signiture and Date *

Preferred Class *

2 Days A Week, $160 Per Month with $150 Registration Fee (Mon & Wed)

2 Days A Week, $160 Per Month with $150 Registration Fee (Tues & Thurs)

4 Days A Week, $300 Per Month with $150 Registration Fee (Mon-Thurs)

Your Child Is Not Registered In The Class Until Registration Form And Payment Have Been Received. Please Acknowledge By Checking "Yes" *

Yes

Total Amount

Payment method

Paypal

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*