Registration Form
Grow In Peace Learning Center
Email address *
Child's First Name: *
Other names child goes by:
Last Name: *
Gender *
Birth date *
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Anticipated Start Date: *
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With whom does the child reside? *
Parent First Name: *
Parent Last Name: *
Phone: *
Email Address: *
Occupation/Employer:
Address: *
Parent Name: *
Parent Last Name: *
Phone: *
Email: *
Occupation/Employer
Address if different from Parent 1
Other Children in the Family (Names and Ages)
Others Living with Child and Relationship
Do have a church you regularly attend? *
If Yes, Name of Church/Organization and Pastor's Name
I am interested in more information about Peace
Clear selection
Desired Schedule: (5 full days can include drop off anywhere from 6:30-6pm maxing at 10 hours of care per day) *
Required
What time will you typically Drop off your child: *
What time will you typically Pick Up your Child? *
1. Authorized Pick up Name and Phone Number *
Persons Authorized to pick up my child other than guardians
2. Authorized Pick up Name and Phone Number *
Persons Authorized to pick up my child other than guardians
3. Authorized Pick up Name and Phone Number *
Persons Authorized to pick up my child other than guardians
Persons Not Authorized to pick up my child: *
if this person is a parent, please send in appropriate custody documents
1. Emergency Contact *
Name, Phone, Email
2. Emergency Contact *
Name, Phone, Email
3. Emergency Contact *
Name, Phone, Email
Does the child have any allergies? *
If Yes,
Clear selection
Does your child have any other special consideration we should be aware of?
Does your child have an IEP?
Clear selection
By typing name below, you agree to the following statement: I understand that Grow In Peace Learning Center Policies and Procedures are available on the website, and that I have access to them. I may also request a paper copy by request. By signing below, I agree to comply with Grow In Peace Learning Center Policies and Procedures. *
Reason for applying to Grow in Peace Learning Center?
Parent Signature
Your Child's enrollment will be confirmed by director after registration form is submitted. There is an annual enrollment fee of $85.00 per child or $150/family.
Parent Signature
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A copy of your responses will be emailed to the address you provided.
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This form was created inside of Peace Lutheran Church. Report Abuse