SECURITY: For your comfort and the safety of our students, all of our facilities are equipped with state of the art video equipment that films all activity in every classroom 24/7.

If you have any questions on how to fill out the form below, please feel free to contact us by clicking on the contact page tab above and send us an email. If your need is time sensitive, please call us at (201) 798 - 1234 Extension 309. If not during business hours, please leave a message and we will get back to you A.S.A.P.

If any area below does not apply, simply LEAVE IT BLANK.

Name

Enter your full name (First + MI) + (Last Name)

First Name

Last Name

Email Address

Subject

Message

Student's Full Name(s)

Enter multiple names if necessary (First, MI, Last) per child.

Student's Gender(s)

Enter each child's biological gender (e.g. Joey (m), Stevie (f))

Child #1 Birthdate

Enter first child's birthdate

YYYY

Child #2 Birthdate

Enter second child's birthdate

YYYY

Child #3 Birthdate

Enter third child's birthdate

YYYY

School Grade(s)

Enter child(ren)'s school grade as of September of present calendar year (eg. Timmy K, Suzy 1st)

Medical Alerts (Allergies)

Enter any allergies or special instructions for each child.

Father's Name

First Name

Last Name

Mother's Name

First Name

Last Name

Guardian's Name

If the child is being cared for by a guardian, please enter guardian's full name.

First Name

Last Name

Child's Address

Enter child's home address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Address

Required only if different from child's address above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact Phone Number

Primary legal contact's number.

(###)

###

####

Father's Phone Number

(###)

###

####

Mother's Phone Number

(###)

###

####

Employer

Enter Company Name. If self employed, enter "Self."

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone Number

(###)

###

####

Emergency Contact

Please enter person to contact in the event of an emergency with your child(ren)

First Name

Last Name

Relationship of Emergency Contact

Please provide relationship of emergency contact provided to the child(ren)

Emergency Contact Phone Number

(###)

###

####

School Pickup Required?

YES

Name of School for Pickup

Pickup School Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What time will pickup be required?

Enter time your child will have to be picked up.

Hour

Minute

Second

School's Cutoff Time for Pickup

Enter the school's cutoff time for pickup in case of emergency

Hour

Minute

Second

Person to Call at School for Pickup

School's Contact Number

(###)

###

####

Child #1 Start Date

Enter date you would like your first child to start at LMP

YYYY

Child #2 Start Date

Enter date you would like your second child to start at LMP

YYYY

Child #3 Start Date

Enter the date you would like your third child to start at LMP

YYYY

Check if self-pay

Check here if you will be paying entirely for your child's tuition

I will be paying

Another or program will be paying or subsidizing

If Not Self-Pay, Who is Paying/Subsidizing?

If you require a subsidy, please indicate who will be subsidizing (e.g. Urban League)

Payment Method (Visa, MC, AE)

Credit/Debit Card Number

This is the credit card you will be using to make payments

Expiration Date (mm/yyyy)

Security Code

Enter security on rear of credit/debit card.

Enter your name for authorization

Address for Credit Card

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Day and Time to Contact You

Enter the day of the week and time to best contact you.

ADMISSION

CONVINCED?

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