Little Eyes Enrollment Form

Little Eyes Enrollment Form

Join us to help your child grow, imagine, and explore new opportunities.
Parent/Guardian Information
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
What city do you live in? (NC residence)
Child Information
Child's Full Name

First NameLast Name
Age
Current Grade
School Name
Child Interests & Background
What are your child's strengths?
What are your child's interests or favorite activities?
Are there any challenges your child is facing that you'd like us to know about?
Essay Questions (THE CHILD FILLS THIS OUT!)

Response needs to be at least 100 words
Describe yourself in your own words. Tell us about you!
Why do you want to join Little Eyes?
What do you hope/want to gains from this experience?
Tell me about your dreams. What do you want to be and what would you like to experience?
Program Selection
Which Little Eyes program are you interested in?

Other
Please indicate your preferred days/times for program participation.

Other
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Relationship to Child
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Permissions & Agreements
I give permission for my child's photograph or video to be taken and used for program purposes.
I agree to allow my child to participate in all program activities.
Signature for permission
Additional Support
Does your family need support with any of the following? (Select all that apply)

Other
Please share any additional information or support needs.
Should be Empty:

Little Eyes Enrollment Form

Parent/Guardian Information

Child Information

Child Interests & Background

Essay Questions (THE CHILD FILLS THIS OUT!)

Program Selection

Emergency Contact Information

Permissions & Agreements

Additional Support