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
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.
Days child will be in attendance:
Monday
Tuesday
Wednesday
Thursday
Friday
Drop Off Time
Pick Up Time
Signature
Submit
Should be Empty: