Pre-K, Early Pre-K & Afterschool Registration Form
Sign in to Google to save your progress. Learn more
Email *
Do you receive subsidy childcare through the ELRC program? *
When would you like your child to start? *
MM
/
DD
/
YYYY
What program(s) are you signing up for? *
Required
What time will your child arrive at the center? *
Time
:
What time will your child be picked up daily? *
Time
:
What school does your child or children attend? *
Does your child struggle with reading or math, if so which subject?
How did you learn about Endless Potential Learning Academy? *
Parent 1 Name *
Parent 2 Name

Child 1 Name

Child 2 Name
First and last name
Child 3 Name
Child 1 Birthdate  *
MM
/
DD
/
YYYY
Child 2 Birthdate
MM
/
DD
/
YYYY
Child 3 Birthdate
MM
/
DD
/
YYYY
Cell phone number

 *
Work phone number *
*
Health Insurance Company upmc *
Health Insurance policy number *
Allergies, dietary restrictions  *
Please list any past and current illnesses that may create problems while at the program.


Mailing Address
Including City, State, & Zip Code

 *
Phone number *
Emergency Contact 1
 
 *
Emergency Contact 1 telephone number *
Emergency Contact 2

 *
Emergency Contact 2 telephone number *
Emergency Contact 3
Emergency Contact 3 telephone number 
Whom may your child be released to? *
I give permission for photos/ videos for local promotion to be taken. (children will not be identified by name). *
The child/ children named above is in good health and I consider him/her capable of the activities taking place. I agree for him/her to take part in youth activities. In the event of an accident I consent to any necessary medical treatment . In an emergency I consent to treatment by medical health professionals, if considered nece *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Endless Potential LLC.

Does this form look suspicious? Report

Google Forms