Ivy League Kids 2021 Enrollment

Ivy League Kids

After School Program
Child's Information
Child's Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What is your child's date of birth? *

Month Day Year
Date
What is your child's gender? *

Male Female
What school grade is your child in? *
What is the name of your child's school? *
Which days per week do you plan for your child to attend? (Select All That Apply)

Monday Tuesday Wednesday Thursday
Parent/Guardian Information
Parent/Guardian's Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Secondary Number or Work Number *
Email address *
example@example.com
Emergency Contact 1: In the event of an emergency, please contact:
First name *
Last name *
Primary phone number *
Emergency Contact 2: In the event of an emergency, please contact:
Name *

First Name Last Name
Primary Phone Number *
Please enter a valid phone number.
Other people authorized to pick up your child from Ivy League Kids:
Name *

First Name Last Name
Name *

First Name Last Name
Medical information
Please list any of the following: Current medications, medication allergies, food allergies, chronic health concerns or any other information we need to know about your child. *
Should be Empty: