Language
English (US)
Spanish (Latin America)
Child's Information
Child's Name
First Name
Last Name
Gender
Female
Male
Other
Desired Start Date
Preferred Nickname
Date of Birth
-
Month
-
Day
Year
Age
Race
African or African American
Asian
American Indian or Alaska Native
Caribbean
Hispanic or Latin American
Indian
Middle Eastern
Native Hawaiian or Other Pacific Islander
Other
Applicant Photo
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Child's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Parent/Guardian Name
First Name
Last Name
Occupation
Parent/Guardian Name
First Name
Last Name
Occupation
Family Email
example@example.com
Family Phone Number
Please enter a valid phone number.
Child Lives With:
Mother
Father
Grand Parents
Other relatives
Guardian
Other
Please give other parent/guardian and emergency contact information
Any relevant information you want to add
School Last Attended
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Who will be financially responsible for weekly tuition?
Mother
Father
Both Parents
Childcare Assistance
Other
Has the child ever been dismissed from an academic institution or program?
Yes
No
Does the child have an IEP? If yes, please email a copy to the center.
Yes
No
Other Information
Please select any delays you may suspect
Delay in speech and language skills
Delay in development skills
Delay in motor/physical development
Delay in social/behavioral skills
Other
Please select any medical and/or psychological diagnoses the child currently has
Asthma
Autism / PDD
Speech Disorder
Vision Problems
Birth Injury
Behavior Diagnosis
Hearing Problems
Heart Problems
Physical Impairment
Seizures / Epilepsy
Traumatic Brain Injury
Genetic Disorder
NONE
Allergies
Other
Type a question
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Date
-
Month
-
Day
Year
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