Clone of EI Group

Little Learners CollectiveA Pre-K Social Learning Group for Ages 3–5

Registration Form
Registration Form

Groups are held at 800 Kinderkamack Road Suite 304N, Oradell, NJ 07649 at 1-2PM at dates below - parent/caregiver required to participant
Participant Name*

First NameLast Name
Age (should be 3-5 years-old)*
Date of Birth*

MonthDayYear
Does your child have any diagnosed developmental delays, allergies, or medical conditions? Please be specific.*
Please indicate below if you provide consent for your child's photo/likeness (i.e. images of their hands/back of their head) to be used from any groups for the purposes of marketing for the practice*

Yes, I give consent for my child to be photographedNo, I do not give consent for my child to be photographed

Primary Contact Information
Parent/Guardian Name*

First NameLast Name
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Name

First NameLast Name
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
CONSENT FOR MEDICAL TREATMENT IN AN EMERGENCY| As the parent or legal guardian of the above-named participant, I hereby give my consent for emergency medical care prescribed by a licensed Doctor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

All 8 Weeks (Jan 15-Mar 5) 1:30-2:30PM$300.00

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Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Little Learners CollectiveA Pre-K Social Learning Group for Ages 3–5