Extended Day Application Form
Please complete an enrollment form for each child you will have attend. Make sure to read the Terms & Conditions for the Extended Day Program before enrolling your child.
Today's Date *
MM
/
DD
/
YYYY
Child's First and Last Name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Age *
Your answer
Gender *
Grade *
Allergies (If any, please list)
Your answer
Medications
Your answer
Any other health concerns
Your answer
Parent/Guardian First and Last Name *
Your answer
Relationship to student *
Your answer
Home address *
Your answer
Phone number *
Your answer
Email *
Your answer
Please Choose One *
List all siblings enrolled at MELA (first and last name)
Your answer
Emergency Contact Name (first and last) *
Your answer
Emergency Contact Relationship to student *
Your answer
Emergency Contact phone number *
Your answer
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