Enrollment and Emergency Contact Form
Parent(s) Name(s)
Contact Number
*
Email Address
*
Parent(s) Name(s)
Contact Number
Email Address
Child's Name
*
Child's Gender
*
Male
Female
What grade will your child in during 26/27 year?
Kindergarten
First Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Kinder Prep (Must be age 4 or 5)
Child's Birthday
*
Does this child have any allergies? If yes please explain their allergies and their reactions. If none, type NA.
Does this child have any disabilities or delays? If yes please explain. If none, type NA.
Address
*
City
*
Please list up to 2 emergency contacts in the event that you can't be reached. List their name, relationship to child and phone number.
Please list all approved people and their relationship that will be allowed to pick child up from the program. They will be required to show ID.
We take pictures of the students when they are doing their activities for our Facebook page. Please click yes if you WILL give permission to have photographs of your child taken
*
Yes
No
Only for my personal update/Brightwheel etc.
Will your child's tuition be paid with ESA?
yes
no
If student is paying with ESA please enter their ESA student number for their invoice. If not using ESA please input N/A.
Do you understand that a $50 registration fee is due immediately with registration. Please let us know how you would like to pay. We can do an ESA invoice to submit through ESA, Venmo or Cashapp.
Signature
Submit
Should be Empty: