Extended day from 3 pm – 5 pm (for the week)

First Name

Last Name

Preferred Pronoun(s)
None She/Her He/Him They/Them Other (please provide additional info in “Accommodations” below)

Birthdate

Child's Age
Calculated automatically from birthdate.

What school does your child attend?

How did you find out about us?

Friends

How can we work better with your child?
If you have any suggestions on how our teachers can work better with your child, please let us know here.

Accommodations
If your child requires any special accommodations, please place them here.

Epi Pen?
None No Yes

Allergies
Does your child have any allergies? If so, please list them here.

Pick Up
Please list the names and numbers of people approved to pick up your child.

Pick Up (Section 2)
Does your child have an individual in their life that has a restraining order or similar order of no contact? If so, please provide additional information on that person.

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