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2015-2016 Diamond Head Keiki Center Admission Application OFFICE USE ONLY: Record #: ___________________ Admission Date: _________________________ Discharge Date: ___________________ Teacher / Caregiver: __________________________________________________ Group assignment: _________________ Other program involvement / Contacts: _______________________________ _______________________________ _______________________________ _______________________________ Child Information First and Last Name Preferred name or nickname Date of Birth Gender: (circle) Male Female Address (including city and zip code) Parent/ Guardian Information Mother’s / Guardian’s Name Contact phone number(s) Address (if different from child’s) Email Father’s / Guardian’s Name Contact phone number(s) Address (if different from child’s) Email How did you hear about our Keiki Center? _____________________________________________________________________ I am interested in this Keiki Center because: (check all that apply) Convenient location Hours of operation are what I need Facilities are attractive School philosophy meets my goals for my child Tuition is reasonable Other: There is a $25 non-refundable application fee. Please make a check out to Salvation Army FTS and send with the completed Application form to: Diamond Head Keiki Center 845 22 nd Avenue Honolulu, Hawaii 96816 You will receive a Space Availability letter upon receipt of this application. Admissions are made year-round. Parent/ Guardian Signature: _______________________________________________________ Date: ____________________ If you have any further questions, feel free to contact us at 739-4931. Aloha!

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2015-2016

Diamond Head Keiki Center Admission Application

OFFICE USE ONLY: Record #: ___________________ Admission Date: _________________________ Discharge Date: ___________________ Teacher / Caregiver: __________________________________________________ Group assignment: _________________ Other program involvement / Contacts: _______________________________ _______________________________ _______________________________ _______________________________

Child Information First and Last Name Preferred name or nickname

Date of Birth Gender: (circle) Male Female

Address (including city and zip code) Parent/ Guardian Information Mother’s / Guardian’s Name Contact phone number(s)

Address (if different from child’s) Email

Father’s / Guardian’s Name Contact phone number(s)

Address (if different from child’s) Email

How did you hear about our Keiki Center? _____________________________________________________________________

I am interested in this Keiki Center because: (check all that apply)

Convenient location Hours of operation are what I need Facilities are attractive

School philosophy meets my goals for my child

Tuition is reasonable Other:

There is a $25 non-refundable application fee. Please make a check out to Salvation Army FTS and send with the completed Application form to: Diamond Head Keiki Center 845 22nd Avenue Honolulu, Hawaii 96816 You will receive a Space Availability letter upon receipt of this application. Admissions are made year-round. Parent/ Guardian Signature: _______________________________________________________ Date: ____________________

If you have any further questions, feel free to contact us at 739-4931. Aloha!