Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Name of Parent 1 *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Name of Parent 2

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Of which town are you a resident? *

(Priority is given to residents of the Up-Island Regional School District. Enrollment is first offered to families residing in Chilmark or Aquinnah, then West Tisbury and then the down island towns.)

Chilmark

Aquinnah

West Tisbury

Vineyard Haven

Oak Bluffs

Edgartown

Preferred Schedule *

(Please select one. School day is 8:00-3:00 pm. Priority is given to families choosing the 5 day option.)

5 Days

4 Days

3 Days