Children’s Learning Center Registration Form

Children’s Learning Center Registration Form
Center Hours:

Fall and Spring:
Monday through Thursdsay
7:00 a.m. - 5:30 p.m.
Friday
7:00 a.m. - 4:30 p.m.
Parent/Guardian Information
I am a KC:*

StudentEmployeeOther/Community Member
KC ID Number:
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home/Cell)*
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Relationship to Child*
Child 1 Information
Name*

First NameLast Name
Current Age*
Birthdate (MM/DD/YYYY)*
Child 2 Information
Name

First NameLast Name
Current Age
Birthdate (MM/DD/YYYY)
Child 3 Information
Name

First NameLast Name
Current Age
Birthdate (MM/DD/YYYY)
Child Care Needs
Monday
Drop off Time:time* Pick up Time:time*

Tuesday
Drop off Time:time* Pick up Time:time*

Wednesday
Drop off Time:time* Pick up Time:time*

Thursday
Drop off Time:time* Pick up Time:time*

Friday
Drop off Time:time* Pick up Time:time*
Expected Start Date (MM/DD/YYYY)*
I certify that the information I have provided is accurate and I understand that this information will be used for billing purposes for the services of the Children's Learning Center.
Signature*

Clear
Date*
Do you need an application for childcare assistance?

YesNo
Should be Empty:

Parent/Guardian Information