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?*

MonthDay Year
Date
What is your child's gender?*

MaleFemale
What school grade is your child in?*
What is the name of your child's school?*
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: