Mommy/Caregiver and Me Registration

Mommy/Caregiver And-Me Registration

Child's Name
First Last
Birthdate*
MM slash DD slash YYYY
Mother Name*
First Last
Mother's Phone*
Mother Email*
Father's Name*
First Last
Father's Phone*
Father's Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Cost
Price:
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Name*
First Last
Billing Address*
Street Address Address Line 2 City State ZIP Code
Please note that the NSHA Mommy/Caregiver and Me program does not offer refunds for missed sessions.
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NSHA NON-DISCRIMINATORY ADMISSION POLICY
NSHA will admist students of any race, color, national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. NSHA does not discriminate on the basis of race, color, national and ethnic origin in the administration of its educational policies, scholarship and loan programs or any other school-administrered programs.