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Parent & Me Program Application

Please note in order to submit your Parent & Me Program Application a processing fee of $50 is due at time of completion.

Step 1 of 5

Child's Name*
First Middle Last
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Upload Family Photo
Accepted file types: jpg, gif, png, pdf, heic, jpeg, Max. file size: 100 MB.
What factors lead you to apply to Cassidy?*
How did you hear about Cassidy?*
If you were referred, please name.
Which other infant/toddler groups have you attended/ do you attend?*

Parent A
Name*
First Middle Last
Relationship to Child*
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Home Phone*
Cell Phone*
Occupation
Parent B
Name
First Last
Relationship to Child
Address
Street Address Address Line 2 City State ZIP Code
Email
Home Phone
Cell Phone
Occupation

Siblings
Sibling #1
First Last
Date of Birth
Month
Day
Year
School Attending
Sibling #2
First Last
Date of Birth
Month
Day
Year
School Attending

Schedule and Billing
Class Day & Time - First Choice
Class Day & Time - Second Choice
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Email*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*