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Infant/Toddler
Summer 2010 Application Form

Please submit one form per child.

Have you been with us before?*	Current Family Former Family New Family
Child's Birthday* (Or Due Date.)	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2006 2007 2008 2009 2010
Gender*	Boy Girl Unknown (Not yet born)
Age Group*	6 Weeks - 18 Months 18 Months - 3 Years
Child's Name*	First: Middle: (optional) Last
Name to be used at school
Child's Address*
City, State, zip*	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Parent/Guardian Information
Parent/Guardian Name*	First Name: Last Name:
Relationship to Child*	Please Select Mother Father Step Mother Step Father Aunt Uncle Family Friend Foster Parent Grandmother Grandfather Legal Guardian
Parent/Guardian Occupation
Parent/Guardian E-mail*
Parent/Guardian Home Phone
Parent/Guardian Cell Phone For Emergency Contact
Place of Business
Business Phone For Emergency Contact
Additional Parent/Guardian Information
Parent/Guardian Name	First Name: Last Name:
Relationship to Child	Please Select Mother Father Step Mother Step Father Aunt Uncle Family Friend Foster Parent Grandmother Grandfather Legal Guardian
Occupation
E-mail
Home Address If different from Child's Address
City, State, Zip	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Home Phone
Cell Phone For Emergency Contact
Place of Business
Business Phone For Emergency Contact
Additional Information
Names & Ages of Siblings
Additional Information
Where did you hear about our program?	Web Lincoln Kids Free Times Word-of-mouth
Payment*	ACH Payment (Withdrawn from Checking or Savings) Payments will be withdrawn from your account on the 10th or the 25th of the month prior to the sessions for which you are registered. Check (Summer Only) If paying by check, payment for all summer sessions is due by May 15th.
Optional Sponsor a Child	I (We) would like to contribute an extra $10 each month to help a child who needs financial assistance. (This is a tax-deductible contribution). Thank You.
Session Information
Sessions*	My child will attend the limited June 1-4 session. My child will attend the June 7 - August 6 Summer Session (closed July 19-23.) Please indicate any days or weeks you will be gone:
If your child will attend the limited June 1-4 session, please select: Tuesday, June 1 Wednesday, June 2 Thursday, June 3 Friday, June 4 __ to 9 a.m. 9 a.m. to 11:30 a.m. 9 a.m. to 3 p.m. 3 p.m. to __ __ to 9 a.m. 9 a.m. to 11:30 a.m. 9 a.m. to 3 p.m. 3 p.m. to __ __ to 9 a.m. 9 a.m. to 11:30 a.m. 9 a.m. to 3 p.m. 3 p.m. to __ __ to 9 a.m. 9 a.m. to 11:30 a.m. 9 a.m. to 3 p.m. 3 p.m. to __
Early Morning Session (Available from 7:45 - 9:00 AM)
Enter drop off time between 7:45-9:00 AM	Mon: Tue: Wed: Thu: Fri:
Sessions* (Full day includes a nap.)	Morning - M/W/F.............9:00 to 11:30 AM Morning - T/Th.................9:00 to 11:30 AM Morning - M thru F...........9:00 to 11:30 AM Full Day - M/W/F.............9:00 AM to 3:00 PM Full Day - T/Th.................9:00 AM to 3:00 PM Full Day - M thru F...........9:00 AM to 3:00 PM
Late Afternoon Session Designed to extend the 9AM - 3PM sessions (Available until 5:00 PM)
Enter pick-up time between 3:00-5:00 PM	Mon: Tue: Wed: Thu: Fri:
A non-refundable Registration Fee of $15.00 is due now. Please send to: Dimensions, 2045 E Street, Lincoln, NE 68510

Confirmations, invoices, and forms will be emailed after April 9. We will call you if a spot is not available.

Note: Fields marked by an asterisk (*) are required.