MRA - Madison Ridgeland Academy

Student's Name
*First
*Middle
*Last
*Preferred
Home Address
*Number & Street
*City
*State
*Zip
*Home Phone	Use xxx-xxx-xxxx format.
*Grade
*Age
*Birthday
*Sex	Male Female

Father's Name
Business/Cell Phone	Use xxx-xxx-xxxx format.
Place of Employment
Business Address

Mother's Name
Business/Cell Phone	Use xxx-xxx-xxxx format.
Place of Employment
Business Address
Mother's Maiden Name

Name of Child's Physician
Office number	Use xxx-xxx-xxxx format.
Allergies or Physical Impairment
Other Comments

*Please choose one of the following Daycare options:
Lunchbunch Drop-in Lunchbunch Tuesdays and Thursdays 11:30 A.M. - 2:00 P.M. $15.00 per day - to be paid on days attended Reserved Lunchbunch Wednesdays 11:30 A.M. - 2:45 P.M. $550.00/Year $55.00/Mo.for 10 months 3:15 Daycare Monday through Friday 11:30 A.M. - 3:15 P.M. $1,350.00/Year $135.00/Mo. for 10 months 6:00 Daycare Monday through Friday 11:30 A.M. - 6:00 P.M. $1,800.00/Year $180.00/Mo. for 10 months

*Please choose one of the following payment options:
Payment in full Attach a post dated check for 8-1-2004 Monthly payment with bankdraft Please complete a bankdraft authorization form and attach a voided check

I agree to the terms of the disclaimer, and agree that the above information is true and correct to the best of my knowledge.
Yes	No

Please attach your check for $25.00 for registration Send all payments and correspondence to: Attn: Cheryl Hendrix Madison-Ridgeland Academy 7601 Old Canton Rd. Madison, MS 39110 All items marked with a are required. **There will be a late charge when your child is not picked up at the specified time.