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Enrollment Form

My child will be attending from:*
Child Name Birth Date Enrollment Date Time From (AM/PM) Time To (AM/PM)

(Use the plus button to add more entries)
My child will be participating in one of the following programs:
Name 5-Day Program (Y/N) 4-Day Program (Y/N) Drop In Only (Y/N)

(Use the plus button to add more entries)
1st Parent/Guardian
Parent’s Name
First Last
Social Security No (last 4 digits)
Home Address
Street Address City State ZIP Code
Parent’s Home Phone Number
Parent’s Work Number
Cellular Phone
Cell Phone Carrier
Email
Employer’s Name and Address
Name Address City State ZIP Code
2nd Parent/Guardian
Parent’s Name
First Last
Social Security No (last 4 digits)
Home Address
Street Address City State ZIP Code
Parent’s Home Phone Number
Parent’s Work Number
Cellular Phone
Cell Phone Carrier
Email
Employer’s Name and Address
Name Address City State ZIP Code
Password
Please provide a password that you would use when someone other than you will be picking up your child.
This form must be completely filled out, signed, and returned. Parents’ Social Security Numbers (last 4 digits) are required for taxes and to log your child in and out every day.
Signature of Parent/Guardian*
First Last
Date*
Email*
Untitled
Name
This field is for validation purposes and should be left unchanged.

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Child Name	Birth Date	Enrollment Date	Time From (AM/PM)	Time To (AM/PM)

Name	5-Day Program (Y/N)	4-Day Program (Y/N)	Drop In Only (Y/N)