Impact Learning Center

1Child Information

First Name *

Last Name *

Date of Birth *

Gender

2Program Selection

Program *

Desired Start Date

3Parent / Guardian Information

First Name *

Last Name *

Relationship to Child

Phone Number *

Email Address *

Street Address *

City

State

ZIP *

Second Parent / Guardian (Optional)

First Name

Last Name

Phone Number

Email Address

4Emergency Contact

Full Name *

Phone Number *

Relationship

5Health Information

Allergies (if any)

Medical Conditions / Special Needs

Physician's Name

Physician's Phone

6Additional Information

How did you hear about us?

Additional Notes or Questions

I confirm that the information provided is accurate and complete. I understand that this is an enrollment request and that a staff member will contact me to confirm availability and complete the enrollment process. I authorize Impact Learning Center to contact me at the information provided above.

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Second Parent / Guardian (Optional)