Registration Form
Please select the location(s) you are interested in attending
Eco Early Academy - Chesterfield (48411 Jefferson Ave, Chesterfield, MI)
Eco Early Academy - Clinton Township (34354 Harper Ave, Clinton Township, MI)
Child's Information
Child's Name
*
First Name
Middle Name
Last Name
Child's Gender
*
Please Select
Male
Female
N/A
Child's Birthdate
*
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Month
-
Day
Year
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Enrollment Details
Preferred Days of care
*
Monday
Tuesday
Wednesday
Thursday
Friday
Intended Drop-off Time
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
AM/PM Option
Intended Pick-up Time
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2
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5
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7
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10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Intended Start Date
*
-
Month
-
Day
Year
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Parent/Guardian Contact Information
Name
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Any additional information you would like to share
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