Pre-Enrollment

Learning Center

Child’s Information:

Child’s Name

Date of Birth // Gender M F

Home Address

City State Zip Code

Home Phone

Mother’s Information

Mother’s Name

Employer Daytime Telephone

Cell Phone Number Email Address

Father’s Information

Father’s Name

Employer Daytime Telephone

Cell Phone Number Email Address

Enrollment:

Expected Date of Enrollment //

I certify that the information give in this document is correct to the best of my knowledge. I am aware that I must pay a non-refundable registration fee in order to secure my child's spot.