Student Name *

First Name

Last Name

Student Birth Date *

MM

DD

YYYY

Student Gender *

Female

Male

Primary Student Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #1 Name *

First Name

Last Name

Phone (Parent/Guardian #1) *

(###)

###

####

Name (Parent/Guardian #2)

First Name

Last Name

Phone (Parent/Guardian #2)

(###)

###

####

Program *

Infant

Toddler

Schedule Preference

Full Time (M-F, 8:30a-3p)

Part Time (3 days/week, 8:30a-3p)

Full Time Extended (M-F, 3p-6p)

Part Time Extended (3 days/week, 3-6p)

3 Hour Cycle - Morning (8:30-11:30a)

3 Hour Cycle - Afternoon (12p-3p)

Payment Preference

Monthly

Quarterly

Half Yearly

Yearly