Little Scholar Academy Interest Forms

I am interested in...

Other

Parent's/Guardian's Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Zip Code

Please choose a location option below:

Are you currently enrolled in Crystal Stairs, Pathway, Connections for Kids program, Children's Home Society of California (R & R programs)

What is your total household size?

Include adults and children.

What is your total household monthly income?

Gross before taxes are taken.

Total Household Size/Income

Please list the name and age of your Child or Children.

Rows	Name	Age	Potty Training
1.
2.
3.
4,

Does your child have any medical conditions or health concerns we should be aware of to ensure their safety and well being while in care:

Does your child have any developmental, behavioral or learning needs we should be aware of to best support them while in care? Please list them below:

Would You like information on Community Resources

How soon are interested in touring our school and possibly beginning the enrollment process:

When would you like to book a Tour Appointment

How did you hear about us?

Total

little SCHOLARS academy