Mighty Oaks Registration 2024

1

Child's #1 Name* This field is required.

First Name

Middle Name

Last Name

2

Child #1 What grade will your child be in for the 24- 25 school year?* This field is required.

6th

7th

8th

3

Child #1 Birth Date* This field is required.

4

Child #1 Gender* This field is required.

5

Child # 2 Name

First Name

Last Name

6

Child #2 - What grade will your child be in for the 24- 25 school year?

6th

7th

8th

7

Child #2 Birth Date

8

Child #2 Gender

9

Parent #1 Name* This field is required.

First Name

Last Name

10

Parent #2 Name

First Name

Last Name

11

Address* This field is required.

Street Address

City

State

Zip Code

Country

12

Primary E-mail* This field is required.

example@example.com

13

Secondary E-mail

(optional)

14

Parent #1 Primary Phone Number* This field is required.

15

Parent #2 Primary Phone Number* This field is required.

16

Emergency contact person #1 First Name *     Last Name *
Phone number #1 *
Relationship to the child   *
Emergency Contact person #2    First Name *     Last Name *
Phone number #2   *
Relationship to the child    *
Authorized pick up person name/ relationship to child    First Name *     Last Name *
Authorized pick up person name/relationship to child    First Name *     Last Name *

17

Child #1 Preferred Care Schedule* This field is required.

18

Child #1 Please select which days you would like your child to attend.* This field is required.

Monday

Tuesday

Wednesday

Thursday

Friday

19

Child # 2 Preferred Care Schedule

21

Please list any medical needs or conditions that should be known to staff. (allergies, dietary needs, ...)

22

Please initial next to the following. I understand that I will be charged a late fee of $1.00/minute for each minute that I am late and arrive after 5:45 pm to pick up my child.    Signature *
I understand I will be charged $10 if I neglect to notify the director, at least one hour prior to dismissal, when my child will be absent on their scheduled day.    Signature *
Any changes to my child's schedule contract will be made two weeks in advance by notifying the Program Director in writing and subject to a $10 fee.    Signature *
My signatures signifies a promise to pay the appropriate monthly amount on a timely basis. Payments are due the before the 5th business day of the each month. After the 5th day a $1/day late fee may be applied to my account.    Signature *

23

24

Date

25

By signing below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.* This field is required.

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