Steps Ahead Learning Center Enrollment Application:

Child’s Full Name:

Child’s DOB: ____/____/____

Street Address: Gender: Male or Female

City: State: Zip:

Parent/Guardian #1 Name: Relation to Child:

Street Address: (only complete if different from child)

City: State: Contact #: ( )

E-Mail: @

Parent/Guardian #2 Name: Relation to Child:

Street Address: (only complete if different from child)

City: State: Contact #: ( )

E-Mail: @

If applicable, siblings currently enrolled or enrolling today: If additional space is needed, please list on the back

1) DOB: ___/___/___ Gender:

2) DOB: ___/___/___ Gender:

If applicable, please list any known allergies of your child:

In the unlikely event of an emergency, please list two contacts, excluding the guardian(s) listed above:

Name: _____________________________________ Contact #: ( )

Name: _____________________________________ Contact #: ( )

Guardian Signature: Date:

Section Below For Director’s Use Only Application Date: ____/____ /____ Deposit Secured?: Y or N Tour Given?: Y or N

Intake Date: ____/____ /____ Classroom Code: _

Waitlisted?: Y or N Date Contacted: ____/____ /____ Notes: