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Enrollment Form

CHILD'S INFORMATION

Child's Birthday
Month
Day
Year
School Type
Please check the boxes to indicate the subjects that your child needs help with (check all that apply) or click enrichment if you're enrolling your child in an enrichment session.
How did you hear about us?
Does your child have any allergies, medical conditions, or an IEP/504 Plan?
Yes
No

PARENT/GUARDIAN INFORMATION

Is your home address the same as the child's as listed above?
Yes
No

OTHER PARENT(S)/GUARDIANS:

Does this person have permission to pick up your child?
Yes
No
Does this person have permission to pick up your child?
Yes
No

PERMISSIONS

Please list the name of any adults who may bring your child to sessions and who have permission to pick up your child

EMERGENCY/ALTERNATE CONTACTS

Who do we have permission to contact regarding your child if you are unable to be reached?

One-Time Registration Fee
$30

I certify that the above information is true and accurate.

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