Pinnacle Kids Academy Pre Enrollment Application Form

Child Information

First Name :

Last Name: (required):

Sex (required):
MaleFemale

Date of Birth (required):

Child's Address (required):

Anticipated Date of Enrollment (required):

Age (required):

What days will child attend Pinnacle Kids Academy (required):
EverydayMonTueWedThurFri

Has child attended childcare before or currently attending one? (required)
YesNo

If yes, name center child is currently attending:

Is child's immunization record complete and up to date? (required):
YesNo

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.