START DATE *

Aftercare will begin on 9.9.2024

MM

DD

YYYY

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Name *

First Name

Last Name

Mother Employers Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother Cell Phone Number

(###)

###

####

Father's Name *

First Name

Last Name

Father Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father Cell Phone Number

(###)

###

####

E1 Name *

First Name

Last Name

E1 Phone *

(###)

###

####

E2 Name *

First Name

Last Name

E2 Phone *

(###)

###

####

Name *

First Name

Last Name

Method of Payment *

Confirmed Program for Parents

Pending Program for Parents

Out-Of-Pocket $80/per week

Other

*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.