Child's Name *

First Name

Last Name

Child's D.O.B. *

MM

DD

YYYY

Confirm Location *

Park Slope

Prospect Heights

I toured PKA already

Yes

No

Not sure

Parent/Guardian *

#1

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Cell Phone *

(###)

###

####

Business address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business phone

(###)

###

####

Parent/Guardian *

#2

First Name

Last Name

Home address

If different from above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

If different from above

(###)

###

####

Cell phone *

(###)

###

####

Business address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business phone

(###)

###

####

Does your child have any siblings?

Yes

No

D.O.B.

MM

DD

YYYY

D.O.B.

MM

DD

YYYY

D.O.B.

MM

DD

YYYY

Pediatrician

First Name

Last Name

Pediatrician address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pediatrician phone

(###)

###

####

Contact person

Director may contact the above for an assessment of your child in a group setting.

First Name

Last Name

Phone

(###)

###

####

Emergency contact *

Please list 3 people other than yourself

First Name

Last Name

Phone *

(###)

###

####

Emergency contact *

First Name

Last Name

Phone *

(###)

###

####

Emergency contact *

First Name

Last Name

Phone *

(###)

###

####

If accepted, I agree to pay monthly tuition *

Yes

No

All payments and deposits are non-refundable *

By accepting, I understand that deposits and fees are NON-REFUNDABLE or NON-TRANSFERABLE

Accept

Do not accept