Parenting Place Summer 2017

NOVA SOUTHEASTERN UNIVERSITY Mailman Segal Center for Human Development Jim & Jan Moran Family Center Village 3301 College Avenue • Fort Lauderdale, Florida 33314-7796 Phone: (954) 262-7127 • Fax: (954) 262-3937 • nova.edu/parenting Current Date______________________________________________________________________ Child’s name (first and last)_ _______________________________________________________ Child’s date of birth _____________________________________ Gender__________________ Child’s NSU ID_ ___________________________________________________________________ PARENT #1 Name (first and last)_______________________________________________________________ Home phone (______)______________________________________________________________ Cell phone (______) ________________ Work phone (______)_ _________________________ Address_ _________________________________________________________________________ City _____________________________ State _______ ZIP (required)____________________ * Email address (MANDATORY FOR REGISTRATION) : __________________________________________________________________________________ ❑ Check here if this is a new address. Is this child currently enrolled in our preschool or Infant andToddler Program? ❑ Yes ❑ No Is this child currently enrolled in the Parenting Place? ❑ Yes ❑ No PARENT #2 Name (first and last)_______________________________________________________________ Home phone (______)______________________________________________________________ Cell phone (______) ________________ Work phone (______)_ _________________________ * Emergency contact person (first and last name)_ ___________________________________ * Emergency contact phone (______)_ _______________________________________________ Refund of Tuition Policy • A 100-percent refund will be given before the start of the first class. • A prorated refund will be given before the third class. • No refunds will be given after the third class, regardless of attendance. Parent’s Initials _____________ MAILMAN SEGAL CENTER FOR HUMAN DEVELOPMENT • 17 Registration/Confirmation Please use one form for each child. Please complete and return form(s) to the Mailman Segal Center. Forms can be found online at nova.edu/parenting/signup. PERMISSION FOR RESEARCH, PHOTOGRAPHS, AND OTHER MEDIA: I/We recognize that the Mailman Segal Center for Human Development of Nova Southeastern University is a teaching and research facility and that observations and research studies are conducted on an ongoing basis. I/We hereby give permission to have my/our child par- ticipate in these studies and be photographed for use in Mailman Segal Center for Human Development brochures or child development publications. SIGNATURE: FOR OFFICE USE ONLY Tuition:_ _________________________________________________________________________ Tuition:_ _________________________________________________________________________ Materials fee:_ ___________________________________________________________________ Discount/credit:_ _________________________________________________________________ Payment: ❑ Cash ________ ❑ Check #________ ❑ Charge ________ CLASS NAME DAY/DATE ( if applicable ) TIME _______________________________ ___________________ ___________ _______________________________ ___________________ ___________ _______________________________ ___________________ ___________ _______________________________ ___________________ ___________ _______________________________ ___________________ ___________ How did you hear about us? ❑ Friend—Please include a name so we can say thanks._ ________________________ ❑ Magazine ❑ Store ❑ Website ❑ Other—Specify_____________________ Payment Option1 Please charge my: ❑ VISA ❑ MasterCard ❑ American Express Expiration date: _____________________ Cardholder’s signature:_ ___________________________________________________ or Payment Option2 ❑ Enclosed is my payment of $_____________________________________________ For multiple registrations by credit card, please use separate registration forms with credit card information for each family. Credit card payment will be accepted for cardholder’s family only.Thank you. * mandatory, if not already on file