AKCDC ENROLLMENT REGISTRATION APPLICATION

ENROLLMENT REGISTRATION APPLICATION

Complete 1 Form per Child
Child's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Enrollment Type:*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from Home Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Information
First Name:Mother's Frist Name  Last Name: Mother's Last Name
SS#:Mother's SS# Employer:   Mother's Employer   Job Title:Mother's Job Title
Work Phone:Mother's Work Phone Cell Phone:Mother's Cell
Email:    Mother's Email
Father's Information
First Name:Father's First Name  Last Name: Father's Last Name
SS#:Father's SS#  Employer: Father's Employer Job Title: Father's Job title
Work Phone:Father's Work Phone Cell Phone:Father's Cell
Email:   Father's Email
Child Lives with:*

Both ParentsMotherFatherLegal GuardianOther (please specify)
Who is authorized to pick-up child? (check all that apply)*

MotherFatherLegal Guardian (provide contact details below)Other (provide contact details below)
Emergency Contacts / Authorized to Pick-up Child (other than
parent/legal guardian) Must enter at least one emergency contact

Contact #1
First Name:Contact1 First Name*  Last Name: Contact1 Last Name*
Relationship to Child:Contact1 Relationship to Child* Cell Phone:Contact1 Cell Phone*
Street Address:Contact1 Street Address*
City:Contact1 City*   State:Contct1 State*  Zip:Contact1 Zip*

Contact #2
First Name:Contact2 First Name   Last Name:Contact2 Last Name
Relationship to Child:Contact2 Relationship to Child  Cell Phone:Contact2 Cell Phone
Street Address:Contact2 Street Address
City:Contact2 City   State:Contact2 State  Zip:Contact2 Zip

Contact #3
First Name:Contact3 First Name   Last Name:Contact3 Last Name
Relationship to Child:Contact3 Relationship to Child Cell Phone:Contact3 Cell Phone
Street Address:Contact3 Street Address
City:Contact3 City  State:Contact3 State  Zip:Contact3 Zip
Please choose payment method:*
Who is responsible for payment / charges not covered by Block Grant?*

FatherMotherLegal GuardianOther (please specify)
How did you hear about us?

FacebookWeb SearchReferralExisting/Previous CustomerPassed by buildingOther (please specify)
Please type any comments / additional information below...
Today's Date*

MonthDayYear
Date
Name of Person Completing Enrollment Form*

First NameLast Name
Email*
example@example.com
Certification*

By clicking this box, I attest that the information provided is accurate.
Please verify that you are human*
Should be Empty: