Pre-Registration Form
Welcome to Liberty of Learning Center, LLC located at 2049 Brodhead Road in Hopewell, PA. We are accepting applications but spots are limited. *Please note that completing this form does not guarantee admission. Thank you for your consideration. If you have any questions, please email libertytreeoflearning@gmail.com or call our office at (724) 203-0089.
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Full name of child
First Name
Middle Name
Last Name
Gender
Boy
Girl
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child have any allergies, special needs or other information that we need to know?
Please Select
Yes - Please explain below.
No
I don't know
List any allergies or special needs for your child here.
Parent or Guardian Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who has parental responsibility?
Mother
Father
Guardian
Please specify
Person authorized to pick up child
First Name
Middle Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Person to call in case of emergency
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
When would you like to start services?
Please Select
As soon as possible
Upcoming School Year
Signature of parent/guardian
Date of Application
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty:
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