Wait List for Prism Education Center

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Child's Name *

What is the child's name? (First, Last)

Child's Date of Birth *

If your child is not yet born, please list your due date

YYYY

Name of Primary Caregiver *

What is the name of the child's primary caregiver? (First, Last)

Phone Number for Primary Caregiver *

What is the best phone number we can use to reach you? (PPP) PPP - PPPP

Email Address *

What is an email address that we can contact you?

Desired Start Date *

What day would you like your child to start? (MM/DD/YYYY)

YYYY

Preferred Schedule *

Part Time (Mon/Wed/Fri)

Part Time (Tue/Thu)

Full Time

Flexible

Does family have multiple children? *

If no, put no. If yes, please submit a new wait list form for each additional child you wish to add to the wait list.

Yes, I will complete an additional wait list form for my other children

Yes, I am not interested in enrolling my other children

Financial Assistance *

Is your family in need of financial assistance? To view the current rates, go to this link http://prismeducationcenter.org/admissions/tuition

Yes

I receive vouchers from DHS

How did you hear about Prism? *

How did you hear about Prism?

Other Information

Please list any other pertinent information.

Submit

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