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Center Enrollment Form

Center Enrollment Form

Child's Information

Please complete a separate form for each child

Admission Date

E-mail Address

Are you enrolling for

Pre-Kindergarten

Toddler Program

Infant Program

Before School Care

After School Care

Before & After Care

Summer Program

Child's Name

Child's Name

First

First

Last

Last

Date of Enrollment

Child's Address

Child's Address

Child's Address

Child's Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Date of Birth

Phone Number

List the school that your child attends if applicable

School Bus Service

Method of Payment

Money Order

Voucher

Check

Credit Card (Pay Online)

Parent's Information

Mother's Name

Mother's Name

First

First

Last

Last

Mother's Address

Mother's Address

Mother's Address

Mother's Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Mother's Phone Number

Mother's Work Number

Work Address

Work Address

Work Address

Work Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Father's Name

Father's Name

First

First

Last

Last

Father's Address

Father's Address

Father's Address

Father's Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Father's Phone Number

Father's Work Number

Father's Work Address

Father's Work Address

Father's Work Address

Father's Work Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Contacts

In case of an emergency contact

Name

Name

First

First

Last

Last

Phone Number

Work Number

Alternate Name

Alternate Name

First

First

Last

Last

Phone Number

Work Number

Drop Off and Pick Up

Name person(s) dropping off and picking up your child at the center

Name person(s) dropping off and picking up your child at the center

First

First

Last

Last

Phone Number

Alternate Person

Alternate Person

First

First

Last

Last

Phone Number

Drop off Time

Pick up Time

Name of the person who will be picking up your child from the center

Name of the person who will be picking up your child from the center

First

First

Last

Last

Phone Number

If you are human, leave this field blank.

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