Application

We offer 5 day, 3 day, and 2 day programs

Please download or fill out Enrollment Form below and Send $50.00 enrollment fee with the application.

Child Enrollment

Child Information

Child's Name *

Date of Birth *

Age at Admission *

Date of Admission *

Child's Home Address *

Child's Home Address

Home Phone Number *

Primary Language *

Identifying Marks

Eye Color *

Hair Color *

Skin Color *

Sex *

Height *

Weight *

Parent/Guardian Information

Parent/Guardian Name *

Relationship to Child *

Reachable Phone Number *

Email Address *

Home Address *

Home Address

Business Name *

Business Phone Number *

Hours at Work *

Business Address *

Business Address

Parent/Guardian 2 Information

Parent/Guardian Name

Relationship to Child

Reachable Phone Number

Email Address

Home Address

Business Name

Business Phone Number

Hours at Work

Business Address

Additional Information

Child's Physician *

Phone Number *

Address *

Address

Allergies/Special Diets?

Individual Health Plan for child with a chronic health condition? *

Yes

Copies of any custody agreements, court orders, and restraining orders pertaining to the child? *

Yes

Please Attach *

Maximum upload size: 2.1MB

Please Attach *

Maximum upload size: 2.1MB

Special limitations or concerns?

School Age Only

Current School

School Phone Number

School Address

I certify that documentation of physical examination and immunizations in accordance with public school health requirements and lead poisoning screening in accordance with public health requirements are on file at my child’s school. Parent/Guardian initials:

Parent/Guardian Signature *

Clear

Date *