Enrollment Information

Which option(s) do you want for you child?
M-W-F Option
M-W-F Option

Tu - Th Option
Tu - Th Option

CHILD'S NAME (First Name Only, unless last name is different

CHILD'S AGE as of today's date.

Child's DOB

GENDER

ADDRESS

CITY

STATE

ZIP

ADDITIONAL PARENTGUARDIAN ADDRESS if different than above

HOME PHONE

PRIMARY CONTACT PHONE

1 Parent/Guardian Name

1 Parent/Guardian OCCUPATION - EMPLOYER ADDRESS

1 Parent/Guardian CELLULAR

1 Parent/Guardian PRIMARY EMAIL

2 Parent/Guardian Name

2 Parent/Guardian OCCUPATION EMPLOYER ADDRESS

2 Parent/Guardian CELLULAR

2 Parent/Guardian PRIMARY EMAIL

Refer-Friend
Refer-Friend

Refer-FB
Refer-FB

Refer-Craig
Refer-Craig

Refer-Sign
Refer-Sign

Refer-Newspaper
Refer-Newspaper

Refer-Other

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