Marina Children's Center
Application for Enrollment
3219A Laguna Street, San Francisco, CA 94123 - (415) 931-0833 http://www.marinachildren.com
Child's Name: _________________________ Nick Name: ___________________________
Male: ____ Female: _______ Date of Birth: _________________________
Home Address: ________________________ City: ________________________________
____________________________________ Zip: _________________________________
Mother's Name: _______________________ Father's Name: ________________________
Home Phone: _________________________ Home Phone: _________________________
Work Phone: _________________________ Work Phone: _________________________
Cell Phone or Pager: ___________________ Cell Phone or Pager: ___________________
Email: _______________________________ Email: _______________________________
Program Preference
Approximate Days Needed: Extended Care:

______ Tuesday & Thursday

______ Monday, Wednesday, and Friday

______ Five Days

______ 4:00 - 6:00
Notes:
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Our $50.00 Application Fee is Non-Refundable
Your child will be place on our waiting list.
See http://www.marinachildren/choices.htm for Enrollment Steps.