Registration Form
Grow In Peace Learning Center
Email address *
Child's First Name: *
Your answer
Other names child goes by:
Your answer
Last Name: *
Your answer
Gender *
Birth date *
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Anticipated Start Date: *
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With whom does the child reside? *
Parent First Name: *
Your answer
Parent Last Name: *
Your answer
Phone: *
Your answer
Email Address: *
Your answer
Occupation/Employer:
Your answer
Address: *
Your answer
Parent Name: *
Your answer
Parent Last Name: *
Your answer
Phone: *
Your answer
Email: *
Your answer
Occupation/Employer
Your answer
Address if different from Parent 1
Your answer
Other Children in the Family (Names and Ages)
Your answer
Others Living with Child and Relationship
Your answer
Do have a church you regularly attend? *
If Yes, Name of Church/Organization and Pastor's Name
Your answer
I am interested in more information about Peace
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: *
Your answer
What time will you typically Pick Up your Child? *
Your answer
1. Authorized Pick up Name and Phone Number *
Persons Authorized to pick up my child other than guardians
Your answer
2. Authorized Pick up Name and Phone Number *
Persons Authorized to pick up my child other than guardians
Your answer
3. Authorized Pick up Name and Phone Number *
Persons Authorized to pick up my child other than guardians
Your answer
Persons Not Authorized to pick up my child: *
if this person is a parent, please send in appropriate custody documents
Your answer
1. Emergency Contact *
Name, Phone, Email
Your answer
2. Emergency Contact *
Name, Phone, Email
Your answer
3. Emergency Contact *
Name, Phone, Email
Your answer
Does the child have any allergies? *
If Yes,
Does your child have any other special consideration we should be aware of?
Your answer
Does your child have an IEP?
Reason for applying to Grow in Peace Learning Center?
Your answer
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.
Your answer
Parent Signature
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A copy of your responses will be emailed to the address you provided.
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