Enrollment Application
(Please complete one per child)
Child Info
Child Name
*
First Name
Last Name
Child DOB
*
-
Month
-
Day
Year
Date
Todays Date
-
Month
-
Day
Year
Date
Child's Age
Child Gender
*
Female
Male
Child Address (include city, st and zip)
*
If school age - enter School Name and Grade
PRIMARY CONTACT PERSONS:
Parent/Guardian 1 Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mom
Dad
Grandparent
Other
Parent1 address same as 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.
Parent 1 Employer Name
Parent 1 Gender
*
Female
Male
Parent 1 DOB
*
-
Month
-
Day
Year
Date
Parent 1 Email
*
example@example.com
Parent/Guardian 2
Parent 2 Name
First Name
Last Name
Parent 2 Relationship to Child
Please Select
Mom
Dad
Grandparent
Other
Parent2 address same as child
Check here if address same as child
Parent 2 Home Address
Parent 2 Cell Number
Please enter a valid phone number.
Parent 2 Employer Name
Parent 2 Gender
Female
Male
Parent 2 DOB
-
Month
-
Day
Year
Date
Parent 2 Email Address
example@example.com
Authorized Pickups/Emergency Contacts
Authorized Pickup 1 Name
Authorized Pickup 1 Cell Phone
Authorized Pickup 2 Name
Authorized Pickup 2 Cell Phone
Authorized Pickup 3 Name
Authorized Pickup 3 Cell Number
Please enter a valid phone number.
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”
*
Is a parent NOT authorized to pickup the child?
Yes (copy of court order is required)
Parent Named in the Court Order
Emergency Information
Name of Physician
*
Physician Address
*
Physician Phone
*
Hospital or Clinic (if you have a preference)
Hospital Address
Hospital Phone Number
Please enter a valid phone number.
Back
Next
Desired Start Date
*
-
Month
-
Day
Year
(this will be confirmed w director once received)
Program Interested in for your Child
*
Please Select
Infant (6wks to 12 months)
Toddler (13 months to 24 months)
2yr Old
3 yr Old
4yr Old
After School
Camps (Winter, Spring, Summer)
*Based on age when your child will start, if not current date
Program Type
*
Please Select
Full Time
2 day Part Time
3 day Part Time
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
*
Please Select
Monthly
Weekly
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
Submit
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