Learning Center Pre-Registration Form

Thank you for your interest. Please complete this pre-registration form and someone from our staff will call you for an appointment to come in and see our facility as well as discuss our fees. 

There is a $65 Registration Fee. Your card will not be charged until you actually register your child(ren) in person and determine their start date.

Primary Parent Name *
Primary Parent Name
Cell Phone *
Cell Phone
Child Name *
Child Name
Child Name #2
Child Name #2
If needed
Child(s) Address *
Child(s) Address
Address of Primary Parent
Child Date of Birth *
Child Date of Birth
1st Child
Child 2 Date of Birth
Child 2 Date of Birth
2nd Child
Work Phone *
Work Phone
Father Name
If needed
Father Name
Father Name
Father Cell
Father Cell
Father Address
Father Address
If different than 1st name
Emergency Contact
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Cell *
Emergency Contact Cell
Child XS- Adult Large
Payment Information
Name on Card *
Name on Card
Visa, MasterCard, etc.,
xxxx-xxxx-xxxx-xxxx
xx/xx
xxx On back of your card
Permissions *
Check all options
Start Date of Care
Start Date of Care