Online Enrollment Form
|
|
Please attach a recent photo of student.
|
|
This is use for identification purposes only.
|
Student's Infomation
|
|
Full Legal Name *
|
|
If student has a middle name, it can be entered in the "Last" field
|
|
Preferred Name
|
|
|
|
Gender *
|
|
Female
Male
|
|
Birth Date *
|
MM
|
/
|
DD
|
/
|
YYYY
|
|
|
Student's Current Age *
|
|
|
|
Reapplying Student? *
|
|
Yes
No
|
|
Is English the Student's primary language? *
|
|
Yes
No
|
|
If no, please specify.
|
|
Language
|
|
Home Phone Number *
|
|
|
Parents / Legal Guardian Names and Home Address
|
|
Parent A/ Legal Guardian Full Legal Name *
|
|
Please indicate Mr., Mrs., Ms., etc.,
|
|
Parent B/ Legal Guardian Full Legal Name *
|
|
Please indicate Mr., Mrs., Ms., etc.,
|
|
Address
|
|
*if Student resides in an addition address, please indicate in Address Line 2
|
Parents A / Legal Guardian Information
|
|
Occupation or Position *
|
|
|
|
Business Number *
|
|
if you do not have a business number, please enter all "000"
|
|
Cell Phone Number *
|
|
if you do not have a cell number, please enter all "000"
|
|
Email Address *
|
|
|
Parents B / Legal Guardian Information
|
|
Occupation or Position *
|
|
|
|
Business Number *
|
|
if you do not have a business number, please enter all "000"
|
|
Cell Phone Number *
|
|
if you do not have a cell number, please enter all "000"
|
|
Email Address *
|
|
|
Program Preference Information
*You may receive additional forms in order to complete your enrollment*
|
|
Check Desired Class *
|
|
Preschool Program
After School
|
|
Term to Enroll *
|
|
Winter/ Spring
2012
Fall 2012
Winter /Spring
2013
|
|
Location to Attend *
|
|
Burlingame
San Mateo
Either One
*by selecting "Either One" the location will be determined based on Enrollment
|
|
Desired Choice Day(s) *
|
|
i.e, Monday-Friday, Tue/Thurs, 2 days, etc.,
|
|
Desired Choice Time(s) *
|
|
i.e, Full Day, Half Day, 9-12p.m., 3:30 - 5:00 p.m., etc.,
|
|
Alternate Choice Day(s) *
|
|
i.e, Monday-Friday, Tue/Thurs, 2 days, etc.,
|
|
Alternate Choice Time(s) *
|
|
i.e, Full Day, Half Day, 9-12p.m., 3:30 - 5:00 p.m., etc.,
|
Medical Information
|
|
Student's Doctor *
|
|
|
|
Doctor's Phone Number *
|
|
|
|
Medical Conditions / Concerns *
|
|
|
|
Medications/ Allergies *
|
|
|
|
Health Insurance and Policy Number *
|
|
|
Emergency Contact
It must be someone who is available and can be easily reach. DO NOT list parents in the spaces below.
|
|
Full Name *
|
|
|
|
Address
|
|
|
|
Phone Number *
|
|
|
|
|
EMF Online Form Builder