Intake Form

Child's First Name(s): *

Child's Last Name: *

Child's Nickname:

Today's Date: *

Child's Date of Birth: *

Age as of Sept 1: *

Gender: *

Applying Parent/Guardian's Full Name: *

Relationship to Child: *

Applying Parent/Guardian's Phone: *

Applying Parent/Guardian's Phone 2:

Applying Parent/Guardian's Email: *

2nd Parent/Guardian's Full Name:

Relationship to Child:

2nd Parent/Guardian's Phone:

2nd Parent/Guardian's Phone 2:

2nd Parent/Guardian's Email:

Anticipated Hours and Days of care: *

Prefer to be contacted by:

How did you hear about us?

Comments:

*A separate application must be filled out for each child in the family who wishes to attend.

Enrollment is confirmed only with written verification from the Director.

Please submit the application form to Tiferes Mordechai. The deposit is $360 for all classes upon acceptance.

Parent / Guardian Signature: (please type full name) *

Date: *

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