Child's Information

    Child's name: (required)

    Child's Date of Birth: (required)

    Address: (required)

    City: (required)

    Home Phone #: (required)

    Current Grade in School: (required)

    Child's Information

    Name of Program: (required)

    Day of Week: (required)

    Time of Day: (required)


    Parent Name: (required)

    Parent Name:

    Parent Email: (required)

    Parent Email:

    Parent Cell: (required)

    Parent Cell:

    Parent Work:

    Parent Work:

    Name(s) of adult(s) who will be picking your child up

    Name: (required)


    Cell: (required)


    Other Information

    What does your child enjoy doing?

    Why are you enrolling your child?

    What do you expect your child to gain from this program?

    Which program are you enrolling your child in?

    Social Stars
    Social Skills Playgroup
    Clubhouse Girls
    Intensive Summer Program