Enrollment Form

Date of Admission

Which program would you like to choose?

Child's Last Name

Child's Home Address (Street, City, Zip)

Date of Birth

Child's Gender

Eye Color

Skin Color

Indentifying Marks

Hair Color

Height (in feet' and inches")

Weight (in pounds)

Primary Language

Allergies, Special Diets, Additional Info

1st Parent/Guardian First Name

1st Parent/Guardian Last Name

Relationship to Child

1st Parent Home Address (Street, City, Zip)

1st Parent Work Address (Street, City, Zip)

1st Parent Best Phone Number

1st Parent Alternate Phone Number

2nd Parent/Guardian First Name

2nd Parent/Guardian Last Name

Relationship to Child

2nd Parent Home Address (Street, City, Zip)

2nd Parent Work Address (Street, City, Zip)

2nd Parent Best Phone Number

2nd Parent Alternate Phone Number

2nd Parent Email Address

1st Emergency Contact First Name

1st Emergency Contact Last Name

Relationship to Child

1st Emergency Contact Home Address (Street, City, Zip)

1st Emergency Contact Best Phone Number

1st Emergency Contact Alternate Phone Number

2nd Emergency Contact First Name

2nd Emergency Contact Last Name

Relationship to Child

2nd Emergency Contact Home Address (Street, City, Zip)

2nd Emergency Contact Best Phone Number

2nd Emergency Contact's Alternate Phone Number

Child's Physician & Clinic Name

Physician Address

Physician Phone Number

Physician's Email

Special Limitations or Concerns?

Please type your full legal name as your electronic signature*

Signed Date (MM/DD/YYYY)