Enrollment Application.pdf


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Enrollment Form
Roots and Wings Learning Center
210 Commerce Lake Drive
Saint Augustine, FL 32095
(904) 940-9410
Date of Birth

Sex

Date of Enrollment

Primary Hours of Care

Child Information
From:
Last Name

First Name

MI

Child’s Address

City

Zip

To:

Nickname
Child Lives With

L

Family Information
Social Security #
Relationship to Child

Address

City

Zip

Home Phone

Cell Phone

Employer

Last Name

First Name

Drivers License #

Relationship to Child

Address

City

Home Phone

Cell Phone

Employer

Work Phone
Social Security #
Zip
Work Phone

Custody


Mother

Father

Both

Other

C

Medical Information
Phone Number
Child’s Dentist

Address

Phone Number

Hospital Preferences
Allergies, special medical or dietary needs or other areas of concern

Tuition: $_________

OFFICE USE ONLY
Registration: $_________ Billing cycle: ____________

Door / ID Code: ________

Contacts _____________________
Program: ________________ Emergency
Classroom: