Coyote Moon Learning Center Enrollment Form

Parent Name

Address

Contact Number

Email Address

Parent Name

Contact Number

Email Address

Child's Name

Child's Gender

Child's Birthday

Child's Grade

Student ESA Number Only if paying with ESA (For Invoice)

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.

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.

What days will child be attending?

What time will your child be dropped off in the morning?

What time will your child be picked up in the afternoon?

Signature

Date

Parental Consent For Media Release