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Little Explorers Enrollment Application
Please fill out this enrollment application to be considered for our Little Explorers program.
* Indicates required question
Email
*
Record my email address with my response
Students last name
*
Your answer
Students first name
*
Your answer
Students Date of Birth
*
MM
/
DD
/
YYYY
Parents full name
*
Your answer
Parents telephone number (preferred number to contact)
*
Your answer
parent's email
*
Your answer
Parents full name
Your answer
Parents telephone number
Your answer
Is the child potty trained?
*
Yes
No
Does child have any allergies?
*
Your answer
Does the child have any health concerns?
*
Your answer
In case of an emergency, if we can not reach you, who is the best person to contact?
Your answer
What is the emergency contacts relation to the child?
*
Your answer
Emergency contacts phone number
*
Your answer
I grant permission for my childs photo to be used on digital media
Yes
No
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