KCLA Summer Learning Program APPLICATION FOR ENROLLMENT
Please complete this application to enroll your child in the KCLA Summer Learning Program.
Student Information
Date of Birth
Sex
Male
Female
Enrollment
Last
First
Middle
Nickname
Child's Physical Address
Primary Hours of Care: From
Primary Hours of Care: To
Days of the Week in Care
Days of the Week in Care
Monday
Tuesday
Wednesday
Thursday
Friday
Family Information
Child's Live with
Mother's Name
Father's Name
Address
Home Phone
Employer
Work Phone
Cell
Custody
Mother
Father
Both
Other (specify)
Submit Application
Should be Empty: