Student Information Form

Part 1/2: Basic Information

*Submitting this form does not guarantee you a spot at our center, please contact us to officially register.

Your Child *
Your Child
Date of Birth *
Date of Birth
Date Beginning School *
Date Beginning School
Home Address *
Home Address
Mother/Guardian *
Mother/Guardian
Mother/Guardian Date of Birth *
Mother/Guardian Date of Birth
Mother/Guardian Phone *
Mother/Guardian Phone
Father/Guardian *
Father/Guardian
Father/Guardian Date of Birth *
Father/Guardian Date of Birth
Father/Guardian Phone *
Father/Guardian Phone
The following individuals, other than guardian(s) listed above, will be allowed to pick up your child from our center. Special exceptions can be made by written consent. (Must bring ID) If none, please enter "N/A"

Part 2/2: Medical information & Authorization

Please print, sign and return to our office.