Form Testing Enrollment Application Step 1 of 4 – Student Information 25% Student Name(Required)Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)Child's Classroom(Required)Please Make a SelectionInfant RoomToddler RoomPreschool RoomPotty training requirement: We require children to be potty trained for our preschool rooms. Please confirm that your child is potty trained, or add notes that you feel might be relevant if they are not.My Child is Potty Trained(Required) Yes, my child is fully potty trained My child is not fully potty trained, see notes Potty Training Notes(Required) Parent/Guardian 1 InformationGuardian 1 Name(Required)Guardian 1 Home Phone(Required)Guardian 1 Employment(Required)Guardian 1 Work Phone(Required)Guardian 1 Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian 1 Email(Required)Parent/Guardian 2 InformationGuardian 2 NameGuardian 2 Home PhoneGuardian 2 EmploymentGuardian 2 Work PhoneGuardian 2 Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Guardian 2 EmailDo both parents live in the same household?(Required)Please Make a SelectionYesNoDoes either guardian currently work at Open Door Health Center?(Required)Please Make a SelectionYesNoEmergency Contact InformationName at least one emergency contact in addition to the guardians listed above.Guardians(Required)NamePhone Number Add Remove Daily Schedule(Required)Please Make a SelectionFull Day (pick up at 5:30 PM)3/4 Day (pick up at 3:45 PM)1/2 Day (pick up at 1:00 PM)Weekly Schedule(Required)Please Make a Selection5 Days/Week (Mon-Fri)3 Days/Week (Mon, Wed, Fri)2 Days/Week (Tue, Thu)OtherOther Weekly Schedule(Required)Enrollment Start Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Enrollment date will depend on availabilityDesired Location(Required)Please Make a SelectionMyrtle AveValley EastAny Open SiteDesired Location(Required)Please Make a Selection10th StreetValley EastMyrtle AveAny Open SiteDesired Location(Required)Please Make a Selection10th StreetM StreetValley EastMyrtle AveAny Open Site Enrollment, Schedule, & Tuition A registration fee will be added to the first month’s bill, as well as an annual supplies fee. Parents will be billed monthly according to the enrollment program agreed upon. Monthly payments are due in full by the 1st. Late fees will be charged if payments are not received on time. It is the family’s responsibility to make sure payment is made even if your child’s regular scheduled day doesn’t fall on the 1st or if you plan to be out of town. Payments can be made on Brightwheel or with cash or a check dropped off at the school. Deposit A deposit is required to hold a spot for 30 or more days. This deposit will be applied to your first month’s bill once your child starts. The deposit is refundable if at least a 30 day notice is given to forfeit your enrollment. Please see our current fees for more details and current fee amounts, and our current tuition rates. Schedule Changes Parents must give a minimum 30 day notice of any schedule change requests. Schedule requests must be approved before changing. Parents are responsible to fill out all proper paperwork before attendance is allowed. This includes a physician report and current updated immunizations for your child. Drop-off time is no later than 9:30am, unless other arrangements were made in advance. Parents must keep all records and forms up to date. A visit with parents/guardians and child are required before the child attends Little Learners. This meeting can be made with the director. We have a 30 day trial period to ensure it’s a good fit for the classroom and child. Signature(Required)
