Pre-Registration Form Christina Learning Center

Christina Learning Center

Pre-Registration Form
Child's Name

First NameLast Name
Child's Age
Age
Child's Date Of Birth

MonthDayYear
D/O/B
Start date care is needed:
Date when care needs to begin.
Parent(s) or legal guardian name:

First NameLast Name
Parent(s) or legal guardian's address
Contact Numbers (Home)
Please enter a valid home phone number.
Contact Numbers (Cell)
Please enter a valid cell phone number.
Email Address:
example@example.com
Employer's name and address:
Please enter your employer's name and address.
Do you need full-time or part-time care?

Full-TimePart-Time
Will multiple children be enrolled in the center? (If yes, discount will apply.)

YesNo
Are you eligible for any subsidy or voucher from any source that will provide full or partial payment of tuition?

YesNo
If you answered (YES), to the above question please explain.
**To secure your child’s placement, an application fee of $25 is due to submit this pre-registration form. This payment will go towards your full registration fee of $100. The full registration fee of $75 will be due at the time of your child’s enrollment.

Pre-Registration Fee

USDThis fee secures your child's placement at Christina Learning Center