NEW ENROLLMENT FORM

Step 1 of 2

Your Name(Required)

First Last

Are you a member?(Required)

Member

Non-Member

Child #1(Required)

First Name

Last Name

D.O.B.

Primary Guardian's Name(Required)

First Last

Primary Guardian's Phone Number(Required)

Secondary Guardian's Name(Required)

First Last

Secondary Guardian's Phone Number

Please list any allergies(Required)

Please put N/A if none.

Is it ok if your child is given a snack by another child?(Required)

Yes

Are there any specific needs your child may need met? Are there any specific items/activities that comfort your child?(Required)

Please list others who are authorized to pick up your child.(Required)

Please put N/A if none.

First Name

Last Name

Phone #

IEP and Behavioral Considerations

Please attach and discuss an IEP with Supervisor and Instructor if your child has one. If your child has any behavioral issues, we reserve the right to remove them from the program.

Max. file size: 16 MB.

Digital Signature(Required)

Please provide your digital signature (first and last name) to confirm that you have read and agreed to the information listed above.

NEW ENROLLMENT FORM

REGULAR HOURS