ENROLL NOW

Child Information

Name*

First Last

Address*

City*

State*

ZIP Code*

Phone Number*

Date Of Birth*

Gender*

Male
Female

Attendance Information

AM Attendance

Days To Attend (AM)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Arrival Time

Departure Time

Meals Required for AM Attendance

Breakfast
AM Snack
Lunch
PM Snack
Dinner

PM Attendance

Days To Attend (AM)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Arrival Time

Departure Time

Meals Required for PM Attendance

Breakfast
AM Snack
Lunch
PM Snack
Dinner

School-Age Attendance

School-Age Out of Session Days To Attend

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Arrival Time

Departure Time

School-Age Out Of Session Meals to Attend

Breakfast
AM Snack
Lunch
PM Snack
Dinner

Enrolling Parent Information

Name*

First Last

Relationship to Child*

Drivers License #*

Address*

City*

State*

ZIP Code*

Email Address*

Home Phone*

Cell Phone*

Work Phone*

Work Extension

Work Address*

City*

State*

ZIP Code*

Work Hours*

Additional Parent Information

Name

First Last

Relationship to Child

Drivers License #

Address

City

State

ZIP Code

Email Address

Home Phone

Cell Phone

Work Phone

Work Extension

Work Address

City

State

ZIP Code

Work Hours

Custody Information

LELA must be provided with court issued custody papers that clearly describe the custody arrangements. Any person granted custody in such papers may pick up the child during the times that person has custody and may designate other persons who are authorized to pick up the child at such times, unless court papers state otherwise.

Parent's Marital Status

Primary Residence

If divorced, who has legal custody?

May the non-custodial parent pick up the child?

Alternate Pick-up Information

First Alternate

Name

First Last

Address

City

State

ZIP Code

Phone

Second Alternate

Name

First Last

Relation

Address

City

State

ZIP Code

Phone

Third Alternate

Name

First Last

Relation

Address

City

State

ZIP Code

Phone

Medical Information

Child's Physician*

Phone*

Any Allergies or Special Needs?*

Hospital Preference*

Emergency Contact Information

Name

First Last

Relationship*

Address*

City*

State*

ZIP Code*

Phone*

Special Needs Information

Is your child potty trained?

Yes
No

What does your child say when they wish to use the toilet?*

Does your child need help dressing?

Yes
No

Does your child need help eating?

Yes
No

Does your child need help washing hands?

Yes
No

Does your child have any special fears or problems?

Yes
No

Has your child been cared for by anyone other than his/her parents?

Yes
No

What is your child's favorite book?*

What is your child's favorite toy/game?*

Miscellaneous Information

Who referred you?

How did you hear about us?

Referred
Drive By
Direct Mail
Internet
Yellow Pages
Ad
Other

Legal Information

I agree to pay a registration fee at the time of enrollment to be renewed each August/September. This enrollment fee is not refundable, but is transferable to another LELA. I agree to pay in advance each week’s tuition. I am aware that I will be charged a fee for payments received after 9:00 A.M on Tuesday. I am aware that I will be charged a fee for late pick-ups. Up to two additional electronic collection attempts and, if needed, by paper draft thereafter will be made to collect on returned checks. The maximum fee allowed by state law will be charged for all collection attempts. You agree to read and download the parent handbook in the Parent Resources section. It is mandatory that all of our Pre School and Pre-K students follow uniform guidelines. This institution is an equal opportunity provider.

Form Acknowledgement

To Digitally Sign this document please check the "Acknowledgement box" and type your full name in the Signature box. You may be asked to physically sign paperwork once you come into our center.

I acknowledge*

Yes

Full Name*

I Acknowledge that by entering my full name above I am signing this application and warrant all information I have entered to be true.

Enrollment Form

Step 1 of 4

Child Information

Attendance Information

AM Attendance

PM Attendance

School-Age Attendance

Enrolling Parent Information

Additional Parent Information

Custody Information

Alternate Pick-up Information

First Alternate

Second Alternate

Third Alternate

Medical Information

Emergency Contact Information

Special Needs Information

Miscellaneous Information

Legal Information

Form Acknowledgement

Permission To Take Child Off Premises Form

Form Acknowledgement

Child's Schedule & Interest Form

Schedule & Interest Form

Form Acknowledgement

Emergency Contact Information

Doctor Information

Miscellaneous Information

Legal Information

Form Acknowledgement