Wait List for Prism Education Center
Prism Employee's Name
Your answer
Today's Date *
Write today's date (MM/DD/YYYY)
Your answer
Child's Date of Birth *
(MM/DD/YYYY)
Your answer
Child's Name *
What is the child's name? (First, Last)
Your answer
Name of Primary Caregiver *
What is the name of the child's primary caregiver? (First, Last)
Your answer
Phone Number for Primary Caregiver *
What is the best phone number we can use to reach you? (PPP) PPP - PPPP
Your answer
Email Address *
What is an email address that we can contact you?
Your answer
Anticipated Start Date *
What day would you like your child to start? (MM/DD/YYYY)
Your answer
Anticipated Start Date 2 *
If the anticipated start date can not be met would you still like to be kept on the list?
Date care no longer needed *
If no, put no. If yes, please put the date (MM/DD/YYYY)
Your answer
Does family have multiple children? *
If no, put no. If yes, put name and date of birth for each.
Your answer
Multiple Children 2
If all of your children are not able to obtain a spot would you still be interested?
How did you hear about Prism? *
How did you hear about Prism?
Your answer
Scholarship *
Is your family interested in scholarships? To view the current rates, go to this link http://prismeducationcenter.org/admissions/tuition
Other Information
Please list any other pertinent information.
Your answer
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