Contact Info
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info@example.com
Mod-friday, 06am -02pm
(123) 456-789
Enroll Now
(123) 456-789
info@example.com
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Child Information
Child’s First and Last Name
First
Last
Gender
Please Select
Male
Female
Prefer not to say
Date of Birth
MM slash DD slash YYYY
Does your child have an IFSP or an IEP?
IFSP (Individualized Family Service Plan, for children under 3)
IEP (Individualized Education Program, for children 3 and older)
No
Parent/Guardian Info
Parent/Guardian Name
Phone Number
Email Address
Address
Street Address
City
ZIP / Postal Code
Emergency & Medical
Emergency Contact (other than parent)
Name
Phone
Relationship
Allergies / Medical Conditions
Program & Permissions
Program/Class Selection
Please Select
Morning
Afternoon
Full Day
After School
Preferred Start Date
MM slash DD slash YYYY
Permissions
I consent to my child’s participation in all activities.
I allow photographs/videos for educational & promotional purposes.
Signature
Parent/Guardian Signature
Date
MM slash DD slash YYYY
