Fountain of Knowledge Learning Center Registration Form

Expected Start Date

MonthDayYear

First Name*

Last Name*

Gender*

FemaleMale

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Doctors Name*

First NameLast Name

Doctors Phone Number*

Area CodePhone Number

Dentist Name*

First NameLast Name

Dentist Phone Number*

Area CodePhone Number

Full Name*

First NameLast Name

Cell*

Area CodePhone Number

Work

Area CodePhone Number

E-mail*

Address - Same As Child*

YesNo

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Parent/Guardian 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Full Name

First NameLast Name

Home

Area CodePhone Number

Cell

Area CodePhone Number

Work

Area CodePhone Number

E-mail

Address - Same As Childs

YesNo

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Does your child have any food allergies?*

YesNo

If yes please list any food allergies.

Does your child have any other allergies?*

YesNo

If yes please list any other allergies.

Does your child have any dietary restrictions?*

YesNo

If yes please list any dietary restrictions.

Does your child have any special needs or health concerns?*

YesNo

If yes please list any special needs or health concerns.

Please tell us about your child's likes and dislikes.

1. Full Name*

First NameLast Name

Relationship to child*

Phone*

Area CodePhone Number

2. Full Name

First NameLast Name

Relationship to child

Phone

Area CodePhone Number

3. Full Name

First NameLast Name

Relationship to child

Phone

Area CodePhone Number

1. Full Name

First NameLast Name

Relationship to child

Phone

Area CodePhone Number

2. Full Name

First NameLast Name

Relationship to child

Phone

Area CodePhone Number

3. Full Name

First NameLast Name

Relationship to child

Phone

Area CodePhone Number

I hereby authorize Fountain of Knowledge Learning Center:

1. To care for my child during the time he/she is in the center.
2. To administer medicine that has been authorized in writing by the parent/guardian.
3. To secure emergency medical care for my child if unable to reach me or those that I have listed on this page.

Signature*

Printed Name*

Date*

Date

Child’s Age Weekly Rate

Under 2 years old..................................................................$175 / week

2 years old – 4 years old............................................................$175 / week

Summer Camp (Ages 5 - 8 years old).....$150 / week

Parents are required to pay a registration fee of $50.00 along with first week's tuition.

It must be understood that to hold your child's space, tuition must be paid whether your child attends or not. Payment is based on contract, not attendance. The registration fee is non-refundable.

Option One: Payment is due on Monday of each week or on the first day of the week attending. If payment is received after Tuesday of each week, a $20 late fee will be charged.

Option Two: Payment is due on the first business day of each month or on the first day of the month attending. If payment is received after the third business day of the month, a $40 late fee will be charged. Tuition X 52 weeks ÷ 12 months = Monthly amount.

A service fee of $35 will be charged for any returned checks.

Signature*

Printed Name*

Date*

Date

I give permission for Fountain of Knowledge Learning Center to take photographs/videos of my child First Name Last Name. I understand these photographs/videos may be used in the classroom, social media, center website, etc.
Yes No*

Signature*

Printed Name*

Date*

Date

Registration Form

Student Information

Mother/Guardian Information 1

Father/Guardian Information 2

Other Infomation

Emergency Contact - Other than Parent/Guardian

Tuition Agreement

Permission to Photograph