LEAPSTART AFTER SCHOOL Enrollment form

LEAPSTART AFTER SCHOOL

ENROLLMENT FORM
Today's Date*

MonthDayYear
Today's Date
Pick School Year for Registration*

2022-23 School year2023-24 School Year
Child's Information
Existing Student?*
Existing Student Name*
Registering siblings?
SIBLING DISCOUNT FOR EACH SIBLING is available for parents registering multiple children
Sibling Names*
Enter sibling names separated by comma
Congratulations! You qualify for Sibling discount calculated as below for both monthly and yearly plans.

5 days monthly: $35 per month for one Child

4 days monthly: $30 per month for one Child

3 days monthly: $25 per month for one Child
First Name*
Last Name*
DOB*

MonthDayYear
Date
Gender*
School Name*
Grade*
Home Street Address*
City*
Zip Code*
State*
Referred By
Any Allergies or other medical conditions that our staff needs to be aware of?
Parents Information
Mother"s Name*
Mom's E-mail*
Mom's Phone*
Mother's Employer*
Father"s Name*
Father's E-mail*
Father's Phone*
Father's Employer*
Emergency Contact & phone
After School Programs
5 Days a week Program

After School until 6:30pm
4 Days a week Program

After School until 6:30pm
3 Days a week Program

After School until 6:30pm
2 Days a week Program

After School until 6:30pmSchool Pick up
Pick days of the week you need services on

MondayTuesdayWednesdayThursdayFriday
Leapstart Location for Enrollment*

De Anza Center, 10594 S De Anza Blvd Cupertino CA 95014Bubb Center, 10650 Bubb Rd Cupertino CA 95014
Requested Start Date

MonthDayYear
Registration Fee (Non Refundable)
Registration Fee*

$150.00
HAVE A PROMO CODE?
Payment Information
PROMO CODE VALUE
Leapstart runs promotions on FB, LinkedIn, Nextdoor occasionally
Final $*
EB Discount
Sibling Discount
Congratulations! You qualify for early bird discount of $50 PER MONTH. Two month's worth discount amount of $100 shall be applied to your total due now.
Calculated Total*

Payment Total*

USDLeapstart After School fee

Pay by Debit or Credit Card

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