Enrollment Application
Fill out the form carefully for registration
Student Name
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Grade Level: (for current school year)
Age:
Hobbies:
Please list hobbies of your child including but not limited to at home hobbies.
Phone Number
Format: (000) 000-0000.
Parent/Guardian Information
Please enter parents/guardian information below
Mother/Guardian Name
First Name
Last Name
Home Address
Physical Address
City, State, Zip
Mailing Address
City, State, Zip
Employer
Work Address
Home Number
Work Number
Cell Number
Email Address
Father/Guardian Name
First Name
Last Name
Home Address
Physical Address
City, State, Zip
Mailing Address
City, State, Zip
Employer
Work Address
Home Number
Work Number
Cell Number
Email Address
Authorized Release & Emergency Information
Your child will only be released to the mother, father, or guardians listed above in addition yo the authorized persons listed below. Legal authorities will be contacted if your child is left at the center one hour after the center closing hours. Please indicate if the persons listed below should be used as on emergency contact
Type a question
Rows
Name
Home Number
Work Number
Emergency Contact
Address
Relation
#1
#2
#3
#4
#5
Person(s) Not Authorized to Pick Child Up:
Medical Information
Child's Pediatrician
Address
Phone Number
Child Has Insurance Coverage
Yes
No
Insurance Information
Company Name
Hospital Preference
My Child has:
an allergy to medicine, food, plant, animal, or insect
a condition or fear that may require special care, procedures, services, medication or diet
none of the above
If you answer yes, please explain:
Program Selection
Please select the program you would like for your child to attend
Which program best suits your child?
Please Select
Before School Care (6am-730am) $25
Basic Membership (3pm-6pm) $40
PREFFERED Membership (3-6:30) $50
Other Information
How did you hear about us?
Parent Referral Name
SIGNATURES
*
By signing below I understand that Crawford's Comfort Zone is an exempt licensening company and agree to all terms and rules of CCZ.
Yes, I agree
No, I do not agree
Need more information
Signature of Parent/ Guardian
Date
Signature
Signature of Director
Date
Signature
All Fees are Non-Refundable
My Products
prev
next
( X )
Early Bird Registration
Registration fee for 2022-2023 school year
$
35.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Print
Save & Continue la
Submit
Should be Empty: