Pre-Registration Form

You can pre-register your child/children on-line. Please fill out the information below and we will contact you regarding our enrollment procedures. Thank-you for your interest. We look forward to having you and your child/children as members of the Bright Minds family.

 

*Required Information

Child #1 Information:

First Name:*

Middle Initial:

Last Name:*

 

Child's Date of Birth:

Month:*

Day:*

Year:*

 

Child #2 Information (If Applicable):

First Name:*

Middle Initial:

Last Name:*

 

Child’s Date of Birth:

Month:*

Day:*

Year:*

 

Child #3 Information (If Applicable):

First Name:*

Middle Initial:

Last Name:*

 

Child's Date of Birth:

Month:*

Day:*

Year:*

 

Street Address:

Address:*

 

City:*

State:*

Zip Code: *

 

Phone:*

Desired Start Date:*

 

Child(ren) resides with:*

 

(Both Parents, Mother, Father, Other-Identify)

 

Registering Parent(s) Information:

Parent First Name:*

Middle Initial:

Last Name:*

Home Phone:*

Work Phone:

Cell Phone:

Email Address: *

 

Parent (2) First Name:

Middle Initial:

Last Name:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

 


Please contact us at 770-948-5535 regarding our rates.