Enrollment Form

1
Name:
First Name
Last Name
2
E-mail:
example@example.com
3
Phone Number:
Area Code
Phone Number
4
Child's Name:
First Name
Last Name
5
Child's Age
6
Child's Birthday:
Date
Month
Day
Year
7
Child's Favorite Activity:
8
What kind of care is your child needing?
Before Care
After Care
All Day Care
9
What days will you need your child in our care?Please select all that apply.
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
10
Starting Date:Please select the date that you would like to begin with Pat-A-Cake Learning Academy.
Date
Month
Day
Year
11
Any additional information:Please list out any additional information you believe we need to have. (ex. allergies, medications, etc.)
Should be Empty: