Pre Enrollment Application Form

Select your Pinnacle Kids Academy location:

Child Information

First Name (required):
Last Name: (required):
Sex (required):
 Male Female
Date of Birth (required):
Child's Address (required):
Anticipated Date of Enrollment (required):
Age (required):
Child will attend Pinnacle Kids Academy (required):
 M Tu W Th F Everday
Has child attended childcare before or currently attending one?
 Yes No
If yes, name center child is currently attending:
Child's immunization record is complete and up to date
 Yes No

Parent Information

Mother
Mother's Last Name (required):
Mother's First Name (required):
Mother's Address (required):
State (required):
Zip Code (required):
Mother's Contact:
Home Phone (required):
Work Phone:
Cell Phone:
Email (required):
Mother's Employer:
Mother's Employer Address:
Father
Father's Last Name (required):
Father's First Name (required):
Father's Address (required):
State (required):
Zip Code (required):
Father's Contact:
Home Phone (required):
Work Phone:
Cell Phone:
Email (required):
Father's Employer:
Father's Employer Address:
Note: This is Pinnacle Kids Academy's pre-enrollment form. Parent will be required to submit a detailed enrollment form in order to complete the application process.