Academic Enrichment Registration — La petite ecole

ACADEMIC ENRICHMENT INQUIRY

All questions with an asterisk (*) are required.

Child's Name

First Name

Last Name

Birthdate:

MM

DD

YYYY

Grade

PARENT INFORMATION

Primary Contact

Name:

First Name

Last Name

Cell phone:

(###)

###

####

Email:

PARENT 2 INFORMATION

Secondary Contact

Name:

First Name

Last Name

Cell phone:

(###)

###

####

Email: