Good Earth Learning Center
Registration
Good Earth Learning Center
Child"s Information
First name
Last name
M.I.
Street address
Street address line 2
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
Date of Birth
*
-
Month
-
Day
Year
Date
Male or female?
Female
Male
Program
*
6 weeks to 18 months
18 months to 30 months
30 months to 6 years
kindergarten
Forest School Camp
Hours of child care required (school hours are 8:00 am to 3:30 pm)
*
Full day
Forest School Camp 9:00-11:00
Days of the week required
*
Monday
Tuesday
Wednesday
Thursday
Friday
Do you require before or after school care? (6am-6pm)
*
Before school
After school
Both
Neither
Parent"s Information
Parent"s/Guardian"s name
Phone number
Place of work
Email address
Parent"s/Guardian"s name
Phone number
*
Place of work
Email address
Emergency Contact 1
In the event of an emergency, please contact:
Emergency Contact First Name
*
Last name
*
Primary phone number
*
Secondary phone number
Emergency Contact 2
In the event of an emergency, please contact:
Emergency ContactFirst name
*
Emergency Contact Last name
*
Primary phone number
*
Secondary phone number
Other people authorized to pick up your child from school
Authorized to Pick up First name
Authorized to Pick up Last name
Phone number
Authorized to Pick up First name
Authorized to Pick up Last name
Phone number
Medical information
Doctor
Doctor"s phone number
Dentist
Dentist"s phone number
Preferred hospital
Insurance/health coverage
Please list any of the following: Current medications, medication allergies, food allergies, or chronic health concerns.
Date of enrollment
-
Month
-
Day
Year
Date
How did you hear about Good Earth Learning Center
Facebook
Sign at business
Friend
Farmers Market
Little Rock Family Magazine
Mailer
Submit
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