MAA Expanded Learning Center Application

Legal Guardian Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Work Phone

Legal Guardian Email *

Legal Guardian 2

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone

Work Phone

Which dates are enrolling your child(ren)? (Select all that apply) *

Year Round
School year only

How many children are you enrolling? *

Desired start date? *

(MM/DD/YYYY)

Child's Name *

First

Last

Date of Birth *

(MM/DD/YYYY)

Additional Child's Name

First

Last

Date of Birth

(MM/DD/YYYY)

Additional Child's Name

First

Last

Date of Birth

(MM/DD/YYYY)

Additional Child's Name

First

Last

Date of Birth

(MM/DD/YYYY)

Additional Child's Name

First

Last

Date of Birth

(MM/DD/YYYY)

Do any of your children have any allergies or health conditions we should be aware of? *

Yes
No

If yes, please explain

Do we have your consent for any or all of the following?

Outdoor play
Sunscreen application
Bug spray application
Using your child(ren's) image(s) for communication or marketing purposes

Emergency Contact (Someone other than Legal Guardian) *

First

Last

Phone *

Relationship to Child *

Alternate person authorized for pickup

First

Last

Phone

Parent Contract Acknowledgement

I have read and understand all contents of the Parental Contract. I understand that by signing this form, I acknowledge and will abide by all written rules and regulations of MAA Expanded Learning Center. The information I have provided is true and accurate to the best of my knowledge.

Name *

First

Last

Date *

(MM/DD/YYYY)

Signature *

Thank you for considering MAA Expanded Learning Center. We look forward to meeting you and your child(ren). If you have any additional questions or concerns please contact us at maalearningcenter@gmail.com or 269-337-0707

Parent Contract Acknowledgement

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