LKR Kids Day In Enrollment

Child's Name*

BoyGirl

Nickname

Birthdate*

Date

Current Date

Date

Age (as of Sept 1, 2023)*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone #*

Area CodePhone Number

Email*

example@example.com

Guardian/Parent Name*

Cell Phone #*

Area CodePhone Number

Work Phone #*

Area CodePhone Number

Guardian/Parent Name*

Cell Phone #*

Area CodePhone Number

Work Phone #*

Area CodePhone Number

Names/Ages of siblings

Additional Emergency/Authorized Pick-Up Contacts:

In addtion to the parent/guardian the following people are authorized to pick up from Little Kids Rock Kids Day In and should be contacted in case of an emergency if a parent/guardiean cannot be reached.

Additional people authorized to pick up your child/children:*

Church Affiliation

How did you hear about our program?

YesNo

Child's Name

BoyGirl

Nickname

Birthdate

Date

Age (as of 9-1-2022)

_________________________________________________

WAITLIST

At this time our classes are full but you will be added to the waitlist for the 2021-2022 school year. Should a spot open up you will be notified in the order that forms are received and payment will be do at that time.

_________________________________________________

Pay now (credit-card)Pay later

Payment

LKR Kids Day In - Non-Refundable Enrollment Fee - Single$50.00

LKR Kids Day In - Non-Refundable Enrollment Fee - Family$75.00

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

2023-2024 Enrollment Form