LIVELY LITERATURE
Registration Form


Parent's Name:  ____________________________________________

Address:        ____________________________________________

City/State/Zip: ____________________________________________

Phone:          ____________________________________________

Email:          ____________________________________________


Child's Name:                    Age:     Desired Age Group:

1.  ________________________     ____     __________________

2.  ________________________     ____     __________________

3.  ________________________     ____     __________________

4.  ________________________     ____     __________________

5.  ________________________     ____     __________________

6.  ________________________     ____     __________________

7.  ________________________     ____     __________________


Fees:

$5.00 per child                                $        5.00

Number of children                             x    ________

                                       Total:  $    ________


Age Group parent prefers to work with:

First Choice:  _______________

Second Choice: _______________


Mail your completed form & check payable to:

Wendy Webb
1107 Dailey Pl. SW
Leesburg, VA   20175-4317