Nihonmachi Little Friends | Enrollment | Application Form: After School Program

Application Instructions:

Please print, complete and sign this form and mail it to NLF. Mail completed forms to the following address:

Nihonmachi Little Friends
Attn: Enrollment
2031 Bush Street
San Francisco, CA 94115

Or you may request materials be sent to you by mail.

Child's Last Name:
Child's First Name:
Date of Birth:
Grade:
Number of Family Members:
Mark an "x" next to one: ___ Single-Parent Family ___Two-Parent Family
Mother's Information:
Name:
Address:
City/State/Zip
Home Phone:
Employer/School:
Address:
Position:
Work Phone:
Father's Information:
Name:
Address:
City/State/Zip
Home Phone:
Employer/School:
Address:
Position:
Work Phone:

Name of school child is/will be attending:
Day and hours program services are needed:
I/we are applying for childcare services because:
In what ways can we serve your child best and/or what do you want your child to obtain from our program:


Income resources of family: Report your total monthly gross family income from all sources. (If you are at the maximum rage or do not wish to disclose this information the maximum fee will be charged.):

I choose to: (put an "x" in one of the following)
	Participate in at least 6 events including all fundraising activities and pay according to the sliding fee scale.
	Not participate and pay at the higher rate.

Signature:
Relationship to child:
Date:

		2031 Bush Street San Francisco, CA 94115 (415) 922-8898 nlfchildcare@yahoo.com