Register

Address*

Phone Number*
- Area CodePhone Number
Does your child have any reading or learning difficulties?*
YesNo
Explain
Parents Information
Father's Name*
First NameLast Name
Father Cell
- Area CodePhone Number
Work Phone
- Area CodePhone Number
E-mail*
Mother's Name*
First NameLast Name
Mother Cell
- Area CodePhone Number
Work Phone*
- Area CodePhone Number
E-mail*
Emergency Contacts
Other than parents
1. Full Name*
First NameLast Name
Phone Number*
- Area CodePhone Number
Relationship*
2. Full Name*
First NameLast Name
Phone Number*
- Area CodePhone Number
Relationship*
Medical Questionaire
Any recent surgery or illness?*
Allergies? (food or medication)*
Yes or No?
Is your child current in his/her immunizations?*
Yes or No?
Does your child take medication regularly?*
Yes or No? If Yes, what kind?
May we give your child Tylenol or Benadryl if needed?*
Yes or No?
Does your child have any mental or social handicap or other problems of which we should be aware of in caring for him/her?*
Family Doctor*
Address*
Phone Number*
- Area CodePhone Number
Payment
Tuition Fee
$500