Basic Information SECTION 1 | BASIC INFORMATION * indicates required field Child's Name* Name child prefers to be called if different than above Child's Date of Birth* Birthplace Gender* Male Female Primary Contact Name* Primary Phone* Primary Email* Program Choice Mon thru Fri Specific Days If you selected Specific Days above, please list those days below Monday Tuesday Wednesday Thursday Friday If program choice is full would you like to be wait listed? Yes No Comments I understand the $100 per family / ($150 for multiple children) enrollment fee is non-refundable.* Parent/Legal Guardian 1* Relationship 1* Parent/Legal Guardian 1 Phone* Parent/Legal Guardian 1 Address* Parent/Legal Guardian 1 Email* Parent/Legal Guardian 1 Place of Employment* Parent/Legal Guardian 2 Relationship 2* Parent/Legal Guardian 2 Phone Parent/Legal Guardian 2 Address Parent/Legal Guardian 2 Email Parent/Legal Guardian 2 Place of Employment Child care provider Child care provider phone Child care provider address Child's brothers/sisters names/ages In case of an emergency, whom do we contact if parents/guardians cannot be reached? Name & Relationship.* Emergency Contact Phone* In addition to myself, the following people have my permission to pick up my child. (Names) The following people MAY NOT pick up my child. (Names) CAPTCHA Code:*
