Enrollment Form | J-NissiLearningCtr

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J-NISSI LEARNING CENTER

Enrollment

Please take a moment to fill out the form.

Children's Information

Child's Full Name

Birthday required

Preferred Name

Home Address

Parent/Guardian's Information 1

(Primary contact)

Full Name

Parent/Guardian 1

Relationship

Email

Cell Phone

Work Phone

Home Address (If different from the above)

Parent/Guardian's 2

Full Name

Relationship

Email

Cell Phone

Work Phone

Home Address (If different from the above)

Emergency Contact

(other than Parents)

First Name

Cell Phone

Work Phone

Relationship

PROGRAM SELECTION

Start date required

Drop off Time:

Pick up Time:

I certify that all the information provided is accurate and complete. I agree to notify the center of any changes to this information.

Your Signature

Thanks for submitting!

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