Enrollment

Enrollment Date

Child's Name*

Date of Birth*

Home Address*

Country*

State*

Zip Code*

Phone Number*

Email Address*

Parent Information

Father Name*

Date of Birth*

Father Work Number

Father Cell Phone Number*

Mother Name*

Date of Birth*

Mother Work Number

Mother Cell Phone Number*

Parent Status MarriedSingleDivorcedSeparated

Employment Status Neither parent or Guardian is employedOne parent or Guardian is employedBoth parent or Guardians are employed

Please list all other children in your Family:

1 Name

Date of Birth

2 Name

Date of Birth

3 Name

Date of Birth

4 Name

Date of Birth

5 Name

Date of Birth

6 Name

Date of Birth

7 Name

Date of Birth

Please indicate your ethnicity by checking one of the options below WhiteBlackAsianAmerican IndianOther

Please list all other children in your Family:

Primary

Secondary

What Are Your Child’s Hobbies?

Government Assistance

Do You Receive Public Assistance? YesNo

Do You Receive Medicaid? YesNo

Do You Receive Food Stamps? YesNo

Emergency Information

Name Of Child*

Date of Birth*

Primary Care Physician

Primary Care Physicians Phone Number*

Insurance Card ID Number

Insurance Name

Please indicate if your Child is allergic to any Medicine

Please indicate if your Child is allergic to Any Food.

In case of an Emergency, please list people who we can contact:

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Upon safety of Your Childs dismissal, Please list the people that can be trusted to pick your child up from school:

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name Of Parent Or Guardian

Government Assistance

Child’s Name

Date of Birth

Is your child allergic to anything? YesNo

Has your child had any head traumas? YesNo

Are your child’s vaccinations up to date? YesNo

Has your child had any surgeries done? YesNo

Does your child have asthma? YesNo

Does your child have eczema? YesNo

Does your child have diabetes? YesNo

Does your child have heat murmur? YesNo

Does your child have seizures? YesNo

Does your child have any dietary problems? YesNo

Please specify if there are any other medical conditions that your child has that you would like us to know

Age/Hours/Price

Toddler (2-3 years)

8:00am-4:00pm $1,200 per month

8:00am-5:00pm $1,300 per month

8:00am-6:00pm $1,400 per month

Nursery & Pre-K (3-5 years)

8:00am-2:20pm FREE per month

Toddler (2-3 years)

8:00am-noon $700 per month

After School Program (3-5 years)

2:20pm-6:00pm $600 per month

Monthly Tuition Rates

Toddler 2s

Full time 8am-4pm 1450

Extended Day Till 5:00pm 1550

Part-Time 5 days a week 8am-12pm.... $950

Part-Time 3 days a week 8am-4pm.... $950

3K Free Full Day

8:00am-4:00pm

Bus Drop-off After School

$600 2:30pm-5:00pm

Registration Fee

$200

Summer Camp

2-5 year olds

$2600 8 week program

Thank you for your trust and consideration.
We look forward to providing only the best of care for
your children!

By submitting this form you agree to the terms of the Privacy Policy.

Enrollment

Afterschool Program

Afterschool Program

Enrollment

Parent Information

Please list all other children in your Family:

Please list all other children in your Family:

Government Assistance

Emergency Information

In case of an Emergency, please list people who we can contact:

Upon safety of Your Childs dismissal, Please list the people that can be trusted to pick your child up from school:

Government Assistance

Age/Hours/Price

Toddler (2-3 years)

Nursery & Pre-K (3-5 years)

Toddler (2-3 years)

After School Program (3-5 years)

Monthly Tuition Rates

Toddler 2s

3K Free Full Day

Bus Drop-off After School

Registration Fee

Summer Camp