Child's Name *

First Name

Last Name

School Term *

Select the term for which you are enrolling the child. Please complete a form for each child being enrolled.

Fall 2023

Spring 2024

Class Days *

Check the one that applies. Check one only.

Tuesday/Wednesday/Thursday

Tuesday/Thursday Only

Wednesday Only

Birthdate of Child *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Name *

First Name

Last Name

Father's Mobile Phone *

(###)

###

####

Father's Business Phone

(###)

###

####

Mother's Name *

First Name

Last Name

Mother's Mobile Phone *

(###)

###

####

Mother's Business Phone

(###)

###

####

1 Emergency Contact Phone *

(###)

###

####

2 Emergency Contact Phone

(###)

###

####

3 Emergency Contact Phone

(###)

###

####

Are Both Parents Living at Home? *

Yes

No

Name of Child's Doctor *

First Name

Last Name

Doctor's Phone *

(###)

###

####

Has Your Child Started an Immunization Program? *

Yes

No

I Give Permission for Photos and Video to be Taken of My Child *

Yes

No

Where Did You Hear About Wickline Day School?

Check all that apply.

Friend

Family Member

Digital Sign on Air Depot

Website

Other (Please Specify Below)

Today's Date *

MM

DD

YYYY