Name ________________________________________ last grade completed ___ k-2, 3-5, 6-9

 

Address ____________________________________

phone ________________

 

age ___________ tiny prince k-2 (only)

 

school attending ______________________________________________

 

parent/guardian ______________________________________________

 

hobbies ______________________________________________

______________________________________________________________

 

goals & dreams______________________________________________

 

____________________________________________________________

 

achievements ______________________________________________

______________________________________________________________

 

 

Comments ...

 

Please return this application to:

Charlotte Patterson
18 East River Street
Ilion, NY 13357

B A C K