Registration - Little Learner Academy

Date of Application

Desired Start Date

Location *

Child's Name *

First

Last

Sex *

Male
Female

Date of Birth *

Home Address *

Address Line 1

City

State

Zip Code

Guardian's Name *

First

Last

Phone

Cell Phone

Email

Place of Business

Is home address different from above?

Yes
No

2nd Guardian's Name

First

Last

Phone

Cell Phone

Email

Place of Business

Is home address different from above?

Yes
No

Will your child be having lunch here? *

Yes
No

How did you learn about Little Learner Academy?

Persons authorized to pick up child and/or be contacted in case of emergency (Other than parent)

This information must be completed

Name *

First

Last

Relationship (to child) *

Phone

Address

Address Line 1

City

State

Zip Code

Name

First

Last

Relationship (to child)

Phone

Address

Address Line 1

City

State

Zip Code

Registration Fee *

Registration is $75 + $25 for each sibling. We accept payment via check, cash, Venmo (@littlelearneracademy), or through Kangarootime. THE REGISTRATION FEE IS NON REFUNDABLE

Parent's Signature *

Date

Little Learner Registration

Welcome to our online enrollment form. This online enrollment form will collect the information needed to help start the enrollment process.

Persons authorized to pick up child and/or be contacted in case of emergency (Other than parent)

Kids

Staff

Years Established

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