CORRECTED DATA FOR 2010 Online Intent to Enroll for Weilenmann School of Discovery

1. CORRECTED INFORMATION

PLEASE COMPLETE THIS FORM IF INFORMATION FOR YOUR STUDENT WAS EITHER INCORRECT OR INCOMPLETE ON YOUR CHILD'S REGISTRATION.

Student Name and Birthdate are required so we can identify the student. Otherwise, only enter that which is incorrect/incomplete on the registration confirmation that you received.

Children who will not be 5 before 9/1/2010 (the requirement for entering kindergarten in the State of Utah) may not register for the 2010-2011 school year.

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1. Child's First Name:

Child's First Name:

2. Child's Middle Name:

Child's Middle Name:

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3. Child's Last Name:

Child's Last Name:

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4. Child's Birth Date: MM/DD/YYYY:
La Fecha de Nacimiento del Niño MM/DD/YYYY

Child's Birth Date: MM/DD/YYYY: La Fecha de Nacimiento del Niño MM/DD/YYYY

5. Parent/Guardian First Name: (Padre/Tutor:)

Parent/Guardian First Name: (Padre/Tutor:)

6. Parent Guardian Last Name:

Parent Guardian Last Name:

7. Street Address: (Domicilio)

Street Address: (Domicilio)

8. City:(Cuidad)

City:(Cuidad)

9. State: (Estado)

State: (Estado)

10. Zip Code: (Codigo Postal)

Zip Code: (Codigo Postal)

11. Phone Number (include area code): Numero Telefonico (incluya el codigo telefonico)

Phone Number (include area code): Numero Telefonico (incluya el codigo telefonico)

12. Alternate Phone Number: (Otro Numero de Telefono)

Alternate Phone Number: (Otro Numero de Telefono)

13. Email: (Correo Electronico)

Email: (Correo Electronico)