Summer Enrichment Application for Superior Start Christian Learning Center

Fall Application for Superior Start Christian Learning Center
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Gender:

MaleFemale
Name you child prefers to be called*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN INFORMATION:
Mother's Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*

Area CodePhone Number
E-mail*
example@example.com
Occupation
Employer
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone

Area CodePhone Number
Father's Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*

Area CodePhone Number
E-mail*
example@example.com
Occupation
Employer
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone

Area CodePhone Number
MEDICAL INFORMATION
Physician Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Please list any Allergies or Existing Medical Conditions*
Does Your Child have an Emergency Action Plan? If yes, please provide a copy to the director for review. Thank you!*

YesNo
Authorized Pick Up

Please list three people who are authorized to pick up your child.
Authorized Person #1*

First NameLast Name
Phone Number *

Area CodePhone Number
Authorized Person #2*

First NameLast Name
Phone Number*

Area CodePhone Number
Authorized Person #3*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact

Please list two Emergency contacts
Emergency Contact Person #1*

First NameLast Name
Relationship*
For example: Father, Grandmother, Family Friend
Phone Number*

Area CodePhone Number
Emergency Contact Person #2*

First NameLast Name
Relationship*
For example: Father, Grandmother, Family Friend
Phone Number*

Area CodePhone Number
Additional Information
Has your child attended any other early childhood programs?

YesNo
If Yes, when and where?
Has your child ever had any health or developmental conditions requiring professional treatment or testing? If yes, please describe.
What are your goals and hopes for your child during their time with us?

Please indicate your preferred schedule for enrollment.

	Full Day	Half Day	Before Care	After Care
Monday
Tuesday
Wednesday
Thursday
Friday

* Full Day - 8:30 a.m. to 4:30 p.m. * Half Day - 8:30 a.m. to 12:30 p.m.

Child care provided beyond an 8 hour full day must be scheduled. There will be an additional charge.

Once your application is reviewed you will receive an enrollment packet and an enrollment deposit invoice equivalent to one week's tuition plus a $35 application fee. Your child's registration is not confirmed until the enrollment deposit has been received. The application fee is non-refundable.
Should be Empty:

Fall Application for Superior Start Christian Learning Center

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

MEDICAL INFORMATION

Authorized Pick Up

Emergency Contact

Additional Information