19/20 Enrichment Enrollment Form

Is your child enrolled in Acera's school year Day Program?

YesNo

What would you prefer to pay now?

Full cost I expect no charges because I am only signing up for full classes and wish to be placed on waitlist

Child information

Child First name	Child Last Name
Date of Birth	Gender
Health/Safety Notes allergies? epi-pen?

Class Information

Choose your trimester

Choose your class

If you select a full class, you will not be charged tuition until your child has been removed from the waitlist and enrolled in the class. An enrichment staff member will be in touch with you about the space availability if spots become available.

Class Cost

Total Cost for all classes

Parent/Guardian 1 Information

Parent/Guardian First Name	Parent/Guardian Last Name	Relationship
Street Address	City	States
Postal Code	Mobile Phone	Work Phone
Home Phone	Occupation	Employer
Email

I have another Parent/Guardian to enter

YesNo

Parent/Guardian 2 Information

Parent/Guardian First Name	Parent/Guardian Last Name	Relationship
Street Address	City	States
Postal Code	Mobile Phone	Work Phone
Home Phone	Occupation	Employer
Email

Payment Information

Total Charges

Name on Card

Card Number

Code

Billing Email

Contact Information