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Parent / Guardian Name *

First Name

Last Name

Child Name *

First Name

Last Name

Child Date of Birth *

MM

DD

YYYY

Child Age *

3

4

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell Phone *

(###)

###

####

Which program are you interested in? *

One of our PreK programs

Before and/or Aftercare (only offered at Longshore location)

Summer Camp

Just shopping around

Do you have access to the following forms? *

If not, we will connect you with a Family Advocate to help you obtain these forms. Please check all that apply.

Your child’s birth certificate

Proof of address

Your child’s insurance card

Proof of income

Current physical and immunization record

Current dental records

Parent ID

None, please connect me to a Family Advocate