Enrollment Form

Name:

Phone:

Email:

Program (Select all that apply)

Summer Care (Full-Time)

Summer Care (Part-time)

2025-26 After School Program (Full-Time)

2025-26 After School Program (Part-Time)

2025-26 After School Program (Wednesdays Only)

Child #1 - First & Last Name

Child #1 Date of Birth

Child # 1 Fall 2025 Grade

Child #2 - First & Last Name

Child #2 Date of Birth

Child #2 Fall 2025 Grade

Child #3 - First & Last Name

Child #3 Date of Birth

Child #3 Fall 2025 Grade

If desiring After School Care, which school(s) does your child attend?