Application for Enrollment

Application for Enrollment

Complete the enrollment form below and make sure all information is accurate and up to date.
Child Enrollment Details
Date Application Completed

MonthDayYear
Date
Child's Date of Birth

MonthDayYear
Date
Child Full Name - Last
Child Full Name - First
Child Full Name - Middle
Child Nickname
Child Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child lives with
Father/Guardian Information
Father/Guardian Name

First NameMiddle NameLast Name
Father/Guardian Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Address (if different from child’s)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Father/Guardian Zip Code
Father/Guardian Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Information
Mother/Guardian Name

First NameMiddle NameLast Name
Mother/Guardian Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Address (if different from child’s)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mother/Guardian Zip Code
Mother/Guardian Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mother/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Contacts
Authorized Contact 1 Name
Authorized Contact 1 Relationship
Authorized Contact 1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Contact 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Contact 2 Name
Authorized Contact 2 Relationship
Authorized Contact 2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Contact 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Contact 3 Name
Authorized Contact 3 Relationship
Authorized Contact 3 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Contact 3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical and Emergency Information
List any allergies and the symptoms and type of response required for allergic reactions
List any health care needs or concerns, symptoms of and type of response for these health care needs or concerns
List any particular fears or unique behavior characteristics the child has
List any types of medication taken for health care needs
Other information for assuring safe medical treatment
Name of health care professional
Health care professional office phone
Please enter a valid phone number.Format: (000) 000-0000.
Hospital preference
Hospital phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorizations and Signatures
I, as the parent/guardian, authorize The Learning Ark to obtain medical attention for my child in an emergency. Signature of Parent/Guardian
Parent/Guardian Authorization Date

MonthDayYear
Date
Should be Empty:

Application for Enrollment

Child Enrollment Details

Father/Guardian Information

Mother/Guardian Information

Authorized Contacts

Medical and Emergency Information

Authorizations and Signatures