Please Fill Out the Form to Register Your Child

Please enter YOUR information below

First Name *

Last Name *

Cell Phone *

Text Opt In *

By checking this box I agree to receive email and SMS text communications and promotions from} about 15 messages a month. SMS text and data rates may apply. I may opt out at any time by replying STOP. View Terms and Conditions at https://heartandmindlearningcenter.com/privacy

Email *

Address *

City *

State *

Zip code *

2nd Parent Full Name

2nd Parent Cell Phone

Child's Full Name *

Child's Date of Birth *

Child's Gender *

Male

Female

Child's Allergies *

Notes about child *

In addition to those listed above, the following individuals may pickup my child:

Authorized Adult 1 Full Name

Authorized Adult 1 Phone

Authorized Adult 2 Full Name

Authorized Adult 2 Phone

Authorized Adult 3 Full Name

Authorized Adult 3 Phone

To keep our preschool running smoothly, please agree to all of these policies:

I agree to pay the monthly tuition by the first class of each month, as well as the non-refundable registration fee to reserve my child’s place and pay for his/her school supplies.

I give permission for my child’s photograph(s) and/or videotaping(s) to be used for preschool marketing materials offline and online, newsletters, and art projects.

I agree to abide by the Policies & Procedures Handbook which I will receive.

Parent Agreement *

I agree to all of the policies listed on this form.

Parent Signature

Clear

Date Signed

(610) 646-5461