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
Next
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