Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Race (Please check all that apply)

Black

Hispanic

Multiracial

White

Other

Enrichment Interests (Check all that apply) *

Art

Legos/Building

Painting

Book Making

Illustrations

STEM

Cooking

Additional Interests

Parent or Guardian's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

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Primary Teacher's Name

First Name

Last Name

Teacher's Number

(###)

###

####

Emergency Contact #1 *

First Name

Last Name

Phone Number *

(###)

###

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Emergency Contact #2 *

First Name

Last Name

Phone Number *

(###)

###

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