Waitlist Program Form
Child Information
Select the program of interest:
Infant/Wobbler/Toddler
Two's
La Escuelita Preschool
WeParent + Me
Big Kids
Summer Camp 2023
Select Your Schedule
*
Full-Time
2-Days (T/TH)
3-Days (M/W/F)
Name of Child (First, Middle Initial, Last):
*
First Name
Middle Name
Last Name
Is the child enrolled in childcare or school? If no, we require full immunization records
*
Yes
No
Date of Birth
*
-
Month
-
Day
Year
Date
Home Phone:
*
-
Area Code
Phone Number
Child’s Home Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent's Information
Guardian(s) of the child(ren)
Parent Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Waitlist Fee
Please pay your non-refundable waitlist fee for the program you have selected.
Name As it appears on the Card
*
Debit/Credit Card Number
*
Expiration Date
*
CVV/CVC Code
*
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I consent to WeVillage charging me in the total amount of $50 non-refundable waitlist fee. I understand that my spot in the selected program is not guaranteed.
Clear
Submit
Should be Empty: