Super Kids Place Registration Form (Point Pleasant)
Email:PPsuperkidsplace@aol.com Phone number (443)320-3570
Child’s Name: ________________________________________________________
Date of Birth: ________________________________________________________
Date of Enrollment: ________________________ Grade: ____________________
Home Phone Number: _________________________________
Work Phone Number: _________________________________
Cell Phone Number: __________________________________
Parent’s Name(s): _______________________________________________________
Address: _____________________________________________________________________________
Email Address: (Please Print Clearly): _______________________________________________________
Indicate which program your child(ren) are registering for:
Mornings (5 day) _____
Morning (3 day) ______ (Circle M T W TH F)
Afternoon (5 day) ____
Afternoon (3 day) ____ (Circle M T W TH F)
Both Morning & Afternoon. Please state which of the two you will be doing. ________________________________________________________
I would like to register my children for enrollment in the program I have attached the $60.00 non-refundable registration fee, per child. (Super Kids Place Inc. takes Cash or Check.
Parents Signature: ____________________________________________ Date: ____________________
Email to: ppsuperkidsplace@aol.com
Super Kids Place
Attn: Elizabeth Bellomy
1035 Dumbarton Rd.
Glen Burnie MD 21060
Email:PPsuperkidsplace@aol.com Phone number (443)320-3570
Child’s Name: ________________________________________________________
Date of Birth: ________________________________________________________
Date of Enrollment: ________________________ Grade: ____________________
Home Phone Number: _________________________________
Work Phone Number: _________________________________
Cell Phone Number: __________________________________
Parent’s Name(s): _______________________________________________________
Address: _____________________________________________________________________________
Email Address: (Please Print Clearly): _______________________________________________________
Indicate which program your child(ren) are registering for:
Mornings (5 day) _____
Morning (3 day) ______ (Circle M T W TH F)
Afternoon (5 day) ____
Afternoon (3 day) ____ (Circle M T W TH F)
Both Morning & Afternoon. Please state which of the two you will be doing. ________________________________________________________
I would like to register my children for enrollment in the program I have attached the $60.00 non-refundable registration fee, per child. (Super Kids Place Inc. takes Cash or Check.
Parents Signature: ____________________________________________ Date: ____________________
Email to: ppsuperkidsplace@aol.com
Super Kids Place
Attn: Elizabeth Bellomy
1035 Dumbarton Rd.
Glen Burnie MD 21060