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ENROLLMENT APPLICATION
Work Entry
Added: 9/7/2024
PARENT #1
First Name
First Name is required.
Last Name
Last Name is required.
Gender
Male
Female
Gender is required.
Phone
Phone is required.
Email
Email address is not valid
Email is required.
Address
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Church Affiliation
Church Affiliation is required.
Employer
Employer is required.
Work Phone
PARENT #2
First Name
Last Name
Gender
Male
Female
Phone
Email
Email address is not valid
Address
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Church Affiliation
Employer
Work Phone
ENROLLMENT INFORMATION
Who does the child(ren) live with?
Who does the child(ren) live with? is required.
Previous Provider
Previous Provider is required.
Reason for Leaving
Reason for Leaving is required.
How did you hear about Connect Academy?
Drove By
Friend/Family
ITOWN Church
Website
Other
How did you hear about Connect Academy? is required.
Why have you decided to enroll with us?
Why have you decided to enroll with us? is required.
Please choose from the following enrollment options:
5 Days: Monday-Friday
3 Days: Tues/Wed/Thurs
2 Days: Monday and Friday
Please choose from the following enrollment options: is required.
Desired Start Date
Desired Start Date is required.
CHILD
First Name
First Name is required.
Last Name
Last Name is required.
Nickname
Birthdate
Birthdate is required.
Gender
Male
Female
Gender is required.
Allergies (Leave Blank if None)
Doctor Name
Doctor Name is required.
Doctor Number
Doctor Number is required.
Additional Child Info
Next
Add Child