KUMON OF OAKLAND MONTCLAIR
1986 Mountain Blvd Oakland, CA 94611
How many child(ren) do you plan to enroll?
*
Single
Multiple
Student Information
Student Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Subject(s) Enrolled
*
Math
Reading
Both
Grade
*
Please Select
PK-3
PK-2
PK-1
K
1
2
3
4
5
6
7
8
9
10
11
12
Name of School
Address
*
Street Address
Street Address Line 2
City
Please Select
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District of Columbia
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Texas
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/ Guardian Information
1st Parent/ Guardian's Name
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
2nd Parent/ Guardian's Name
First Name
Last Name
Email
example@example.com
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Sibling Student Information
Sibling # 1
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Grade
Please Select
PK-3
PK-2
PK-1
K
1
2
3
4
5
6
7
8
9
10
11
12
Name of School
Subject(s) Enrolled
Math
Reading
Both
Sibling # 2
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Grade
Please Select
PK-3
PK-2
PK-1
K
1
2
3
4
5
6
7
8
9
10
11
12
Name of School
Subject(s) Enrolled
Math
Reading
Both
Policies and Procedures
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Please Check
*
Yes, I have read the Policies, Media Release, and E-Payment Agreement
As a Parent or Guardian:
*
Yes, I am ok with my child's pictures and success stories being displayed on the Center's Kumon e-Page only upon approval of the story draft and picture prior to publication
No, I do not wish to my child's pictures and success stories to be on display
Bank Name
*
Account Type
*
Checkings
Savings
Primary Account Holder Name
*
Secondary Account Holder
ABA Routing Number
*
The ABA routing number is typically the first group made up of 9 numbers in the lower-left corner of your check. The account number is the next group of numbers.
Account Number
*
Account Number
*
Parent's Signature
*
Parent's Name
*
Date
*
-
Month
-
Day
Year
Date
Sorry, account numbers must match to reveal the submit button.
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