little SCHOLARS academy
Interest Form
I am interested in...
*
Enrollment
Newsletter
Other
Parent's/Guardian's Name
*
First Name
Last 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:
*
Los Angeles Infant Center & Preschool( 12months-6years)
Long Beach Infant Center & Preschool (12months- 6years)
Are you currently enrolled in Crystal Stairs, Pathway, Connections for Kids program, Children's Home Society of California (R & R programs)
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Yes
No
What is your total household size?
*
Please Select
1-2
3
4
5
6
7
8
9
10
11
12+
Include adults and children.
What is your total household monthly income?
*
Please Select
$0 – $6,128
$6,129 – $6,931
$6,932 – $8,025
$8,026 – $9,309
$9,310 – $10,593
$10,594 – $10,834
$10,835 – $11,074
$11,075 -$11,315
$11,316 – $11,556
$11,557 – $11,797
$11,798 – $12,037
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:
*
Yes
No
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
Food Banks
WIC
Free Diaper and Baby Wipes
Shelter / Housing Referral
Counseling Refferal
Domestic Violence
Regional Center/ LAUSD
Not at this time
How soon are interested in touring our school and possibly beginning the enrollment process:
*
As soon as Possible
Within the next week 1-2 weeks
Within the next month
I'm still exploring options
When would you like to book a Tour Appointment
How did you hear about us?
Google Search
Social Media (Facebook, Instagram, etc.)
School Website
Referral from a Friend or Family Member
Current or Former Parent
Community Event / Open House
Flyer or Printed Materials
Online Directory (e.g., Yelp, Care.com)
Local Organization or Partner
Word of Mouth (General)
Other
Total
Submit
Should be Empty: