Select Campus

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Child Info

First

Last

 
(custody order, restranining order, etc.)


(This shows the first available date at the center)


Parent/Guardian Info
First
Last
Emergency Contact and Authorized Pick-up

Note: Emergency contact MUST be someone other than parent/guardian
First
Last
Allergy and Food Restrictions



Health History
Child's Doctor’s Name *
First
 
Last
Doctor's Phone *
 
Doctor's Address *

If yes, please select and provide the date of illness.



Physical, Language, Cognitive Development
What type of support do you believe would be beneficial for your child? *
Do you have private insurance? *
Immunization Records *

Please Right Click on the links below and download the forms to your computer. Please note that these are fillable forms and will only work with Adobe PDF Reader. You can download the Free Adobe Reader from https://get.adobe.com/reader/.
Statement of Conscience or Religious Belief | Statement of Medical Exemption form

Immunization Records File Upload *

Please provide a copy of the Immunization Records or Statement of Religious or Conscience Belief form | Statement of Medical Exemption form

Note: If you do not have the product information at the moment, please select "No" and provide the details to the center at a later date.
Please use the mouse pointer to draw your signature…


Note: If you do not have the product information at the moment, please select "No" and provide the details to the center at a later date.
Please use the mouse pointer to draw your signature…
Please use the mouse pointer to draw your signature…
Please use the mouse pointer to draw your signature…
Please use the mouse pointer to draw your signature…
Please use the mouse pointer to draw your signature…
Selected Amount:
This is a 5 digit number which identify your bank branch
This is a unique 3 digit number that identify your Bank
This is your account number at the bank. It is usually a minimum 7 digit long.
Secondary Payment
Since a billing amount of less then 100% is selected above, we will require Secondary Payment information for the remaining balance.
This is a 5 digit number which identify your bank branch
This is a unique 3 digit number that identify your Bank
This is your account number at the bank. It is usually a minimum 7 digit long.
Your card will only be charged for the Registration Fee Payment.