Enrollment Application

Enrollment Application
(Fill out one form per preschool child)

AFTER SCHOOL!! Click Here to fill out After School Application
Child Info
Child Name*

First NameLast Name
Child DOB*

MonthDayYear
Date
Todays Date

MonthDayYear
Date
Child's Age
FemaleMale
Child Address (include city, st and zip)*
If school age - enter School Name and Grade
PRIMARY CONTACT PERSONS:
Parent/Guardian 1 Name*

First NameLast Name
Relationship to Child*
Check here if address same as child
Parent1 Home Address (include city, state and zip)*
Parent1 Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent 1 Employer Name
FemaleMale
Parent 1 DOB*

MonthDayYear
Date
Parent 1 Email*
example@example.com
Parent/Guardian 2
Parent 2 Name

First NameLast Name
Parent 2 Relationship to Child
Check here if address same as child
Parent 2 Home Address
Parent 2 Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Employer Name
FemaleMale
Parent 2 DOB

MonthDayYear
Date
Parent 2 Email Address
example@example.com
Authorized Pickups/Emergency Contacts
Authorized Pickup 1 Name
Authorized Pickup 1 Cell Phone
Format: (000) 000-0000.
Authorized Pickup 2 Name
Authorized Pickup 2 Cell Phone
Format: (000) 000-0000.
Authorized Pickup 3 Name
Authorized Pickup 3 Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Please list problems or needs, including known allergies, existing illnesses,previous illnesses and injuries, any disabilities or behavior issues, any hospitalizations during the past twelve months, and any medicationprescribed for long-term, continuous use, and any other information the staff should be aware. ***If none, please write “None”*
Yes (copy of court order is required)
Parent Named in the Court Order
Emergency Information
Name of Physician*
Physician Address*
Physician Phone*
Format: (000) 000-0000.
Hospital or Clinic (if you have a preference)
Hospital Address
Hospital Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Desired Start Date*

MonthDayYear
(this will be confirmed w director once received)
Program Interested in for your Child*
*Based on age when your child will start, if not current date
Program Type*
2 day PT is only offered on T-TH (Days don't change and is paired with 3 day PT which is only M-W-F **Part Time Options are only available for Toddler and Older
Do you want a Monthly or Weekly Payment Schedule*
Monthly Payment schedule deposit is only $100 while the Weekly Payment schedule deposit is $550
Recurring Weekly Payment
Recurring Monthly Payment
Annual Payment
Total Initial Payment to Start
This is based on the payment plan and program you picked above and includes All Fees to start
Form Calculation Payment Total
Enter tuition discount you are approved or eligible, otherwise leave blank
Please write in the % discount, which discount it is for. This will be calculated when your billing account is setup with Brightwheel, it is NOT calculated in the form above.
Signature

Clear
Date

MonthDayYear
Should be Empty:

Enrollment Application

Child Info

PRIMARY CONTACT PERSONS:

Parent/Guardian 2

Authorized Pickups/Emergency Contacts

Emergency Information