Septmber 3, 2024 - May 29, 2025 // Tuesdays and Thursdays // 9-2 pm // Ages 6 weeks - 5 years old (Children who are 4 and under as of September 1, 2024 are eligible for registration.)
First month's tuition and a $100 supply fee is due at meet the teacher night on August 27th, 2024.
(Monthly tuition is due every 1st of the month)
$50 non-refundable registration fee is due at the time of registration.
CHILD INFORMATION:
Child Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
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Month
Please select a day
1
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Day
Please select a year
2024
2023
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Year
Age
*
6 Weeks-12 Months (Little Dreamers)
13 Months-24 Months (Movers and Shakers)
2-3 Year Old (Wild and Free)
4-5 Year Old (Little Legends)
Sex
*
F
M
Is your child potty trained?
*
Yes
No
Child lives with
*
Both Parents
Mother
Father
Other
Please specify of other
PARENT/GUARDIAN INFORMATION:
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Phone Number
*
Parent/Guardian's E-mail
*
example@example.com
Parent/Guardian's Name
First Name
Last Name
Parent/Guardian's Phone Number
Parent/Guardian's E-mail
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMERGENCY CONTACT:
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Emergency Contact Name
First Name
Last Name
Emergency Contact Number
I hereby authorize Rebel Church to allow my child to be picked up by the following persons.
Authorized Person
First Name
Last Name
Contact Number
Authorized Person
First Name
Last Name
Contact Number
Authorized Person
First Name
Last Name
Contact Number
Authorized Person
First Name
Last Name
Contact Number
MEDICAL INFORMATION:
Child's Physician Name
*
First Name
Last Name
Physician's Phone Number
*
Medical Concerns/ Allergies
*
How did you hear about us?
I give permission to have photographs/videos of my child taken during activities. We may use these images/videos on social media or have them displayed in the classrooms.
*
Yes
No
Water Activities: My child is allowed to participate in water activities.
*
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
Date
My Products
*
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Registration Fee
$
50.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
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