Enrolling for What Program? (you must submit a SEPARATE registration form for each child)

Please check the box beside the program for which you are enrolling this child

Cross Centered Academy

Chrissi's Kids Learning Academy

My Brother's Keeper Afterschool Program

Arise and Shine Infant Care

Today's Date

MM

DD

YYYY

Name of Child *

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Child's Grade (if school age)

Kindergarten

First

Second

Third

Fourth

Fifth

Sixth

Seventh

Eighth

Ninth

Tenth

Eleventh

Twelfth

Child's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father/Guardian Name

First Name

Last Name

Father/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father/Guardian Phone

(###)

###

####

Mother/Guardian Name

First Name

Last Name

Mother/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother/Guardian Phone

(###)

###

####

Any Allergies?

If any allergies, please explain in next field

Yes

No