The Learning Circle (Before and After School Care)

Family Name REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Father's Information:

First Name Please enter valid data.

Last Name Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Cellphone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Work Phone Number Maximum 20 characters Please enter a phone number.

Mother's Information:

First Name Please enter valid data.

Last Name Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Cellphone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Work Phone Number Maximum 20 characters Please enter a phone number.

Student Information #1:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Sex REQUIRED Male Female Please fill out this field.
Birth date REQUIRED Please fill out this field. Please enter a date.
Grade REQUIRED Please fill out this field. Please enter valid data.
Room Number REQUIRED Please fill out this field. Please enter valid data.
Please list any special instructions you may have for your child. (i.e.: food allergies, any important medical information, special needs, special diet, etc.)

Student Information #2:

First Name Please enter valid data.

Last Name Please enter valid data.
Sex Male Female
Birth date Please enter a date.
Grade Please enter valid data.
Room Number Please enter valid data.
Please list any special instructions you may have for your child. (i.e.: food allergies, any important medical information, special needs, special diet, etc.)

Student Information #3:

First Name Please enter valid data.

Last Name Please enter valid data.
Sex Male Female
Birth date Please enter a date.
Grade Please enter valid data.
Room Number Please enter valid data.
Please list any special instructions you may have for your child. (i.e.: food allergies, any important medical information, special needs, special diet, etc.)

Student Information #4:

First Name Please enter valid data.

Last Name Please enter valid data.
Sex Male Female
Birth date Please enter a date.
Grade Please enter valid data.
Room Number Please enter valid data.
Please list any special instructions you may have for your child. (i.e.: food allergies, any important medical information, special needs, special diet, etc.)

Emergency Contact #1:

First and Last Name REQUIRED Please fill out this field. Please enter valid data.
Address Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

Emergency Contact #2:

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Address Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.

The following adults may pick up the above student from the learning circle. Please indicate below name of adults authorized to pick up your child:

Name #1 Please enter valid data.
Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Name #2 Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
Name #3 Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
Name #4 Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.
Name #5 Please enter valid data.
Phone Number Maximum 20 characters Please enter a phone number.

Anything else you want us to know: